S. HRG. 109–162

INDIAN HEALTH CARE IMPROVEMENT ACT

JOINT HEARING

BEFORE THE

COMMITTEE ON INDIAN AFFAIRS

UNITED STATES SENATE

AND THE

COMMITTEE ON HEALTH, EDUCATION,

LABOR AND PENSIONS

UNITED STATES SENATE

ONE HUNDRED NINTH CONGRESS

FIRST SESSION

ON

S. 1057

INDIAN HEALTH CARE IMPROVEMENT ACT AMENDMENTS OF 2005

JULY 14, 2005

WASHINGTON, DC

(
INDIAN HEALTH CARE IMPROVEMENT ACT
U.S. GOVERNMENT PRINTING OFFICE

WASHINGTON : 

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Internet: bookstore.gpo.gov Phone: toll free (866) 512–1800; DC area (202) 512–1800

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22–554 PDF 2005

S. HRG. 109–162

INDIAN HEALTH CARE IMPROVEMENT ACT

JOINT HEARING

BEFORE THE

COMMITTEE ON INDIAN AFFAIRS

UNITED STATES SENATE

AND THE

COMMITTEE ON HEALTH, EDUCATION,

LABOR AND PENSIONS

UNITED STATES SENATE

ONE HUNDRED NINTH CONGRESS

FIRST SESSION

ON

S. 1057

INDIAN HEALTH CARE IMPROVEMENT ACT AMENDMENTS OF 2005

JULY 14, 2005

WASHINGTON, DC

(
COMMITTEE ON INDIAN AFFAIRS

JOHN McCAIN, Arizona, Chairman

BYRON L. DORGAN, North Dakota, Vice Chairman

PETE V. DOMENICI, New Mexico

CRAIG THOMAS, Wyoming

GORDON SMITH, Oregon

LISA MURKOWSKI, Alaska

MICHAEL D. CRAPO, Idaho

RICHARD BURR, North Carolina

TOM COBURN, M.D., Oklahoma

DANIEL K. INOUYE, Hawaii

KENT CONRAD, North Dakota

DANIEL K. AKAKA, Hawaii

TIM JOHNSON, South Dakota

MARIA CANTWELL, Washington

JEANNE BUMPUS, Majority Staff Director

SARA G. GARLAND, Minority Staff Director

COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS

MICHAEL B. ENZI, Wyoming, Chairman

JUDD GREGG, New Hampshire

BILL FRIST, Tennessee

LAMAR ALEXANDER, Tennessee

RICHARD BURR, North Carolina

JOHNNY ISAKSON, Georgia

MIKE DEWINE, Ohio

JOHN ENSIGN, Nevada

ORRIN G. HATCH, Utah

JEFF SESSIONS, Alabama

PAT ROBERTS, Kansas

EDWARD M. KENNEDY, Massachusetts

CHRISTOPHER J. DODD, Connecticut

TOM HARKIN, Iowa

BARBARA A. MIKULSKI, Maryland

JAMES M. JEFFORDS (I), Vermont

JEFF BINGAMAN, New Mexico

PATTY MURRAY, Washington

JACK REED, Rhode Island

HILLARY RODHAM CLINTON, New York

KATHERINE BRUNETT MCGUIRE, Staff Director

J. MICHAEL MYERS, Minority Staff Director and Chief Counsel

(II)
(III)

C O N T E N T S

Page

S. 1057, text of ......................................................................................................... 4

Statements:

Brandjord, DDS, Robert, president-elect, American Dental Association ..... 363

Brannan, Richard, chairman, Northern Arapaho Business Council ............ 352

Dorgan, Hon. Byron L., U.S. Senator from North Dakota, vice chairman,

Committee on Indian Affairs ....................................................................... 334

Enzi, Hon. Michael B., U.S. Senator from Wyoming, chairman, Committee on Health, Education, Labor and Pensions .......................................... 1

Forquera, Ralph, executive director, Seattle Indian health Board .............. 353

Grim, Dr. Charles, director, Indian Health Service, Department of Health

and Human Services ..................................................................................... 335

Hartz, Gary, director, Office of Environment Health and Engineering,

Indian Health Service, Department of Health and Human Services ....... 335

Joseph, Rachel A., chairperson, Lone Pine Paiute Shoshone Reservation .. 348

Kashevaroff, Don, president, Seldovia Village Tribe and president Alaska

Native Tribal Health Consortium ................................................................ 350

Kennedy, Hon. Edward M., U.S. Senator from Massachusetts .................... 334

McCain, Hon. John, U.S. Senator from Arizona, chairman, Committee

on Indian Affairs ........................................................................................... 334

McSwain, Robert G., deputy director, Indian Health Service, Department

of Health and Human Services .................................................................... 335

Murray, Hon. Patty, U.S. Senator from Washington .................................... 347

Vanderwagen, M.D., Craig, acting chief medical officer, Indian Health

Service, Department of Health and Human Services ................................ 335

Williard, Dr. Mary, Yukon Kuskowim Health Corporation Dental Clinic ... 361

APPENDIX

Prepared statements:

Anderson, Trudy, President/CEO, Alaska Native Health Board .................. 452

Brandjord, DDS, Robert (with attachment) ................................................... 385

Brannan, Richard ............................................................................................. 440

Cantwell, Hon. Maria, U.S. Senator from Washington ................................. 375

Dorgan, Hon. Byron L., U.S. Senator from North Dakota, vice chairman,

Committee on Indian Affairs ....................................................................... 376

Enzi, Hon. Michael B., U.S. Senator from Wyoming, chairman, Committee on Health, Education, Labor and Pensions .......................................... 377

Forquera, Ralph (with attachment) ................................................................ 456

Friedman, DDS, MPH, Jay W. (with attachment) ......................................... 570

Gottlieb, Katherine, president/CEO, Southern Foundation .......................... 581

Grim, Dr. Charles ............................................................................................. 584

Ignace, Georgiana, president, National Council of Urban Indian Health ... 598

Inouye, Hon. Daniel K., U.S. Senator from Hawaii ....................................... 379

Joseph, Rachel A. (with attachment) .............................................................. 623

Kardos, B.D.S., M.D.S., Ph.D., FFOP (RCPA), Thomas B., professor of

Oral Biology and Oral Pathology, University of Otago, Dunedin, New

Zealand (with attachment) ........................................................................... 643

Kashevaroff, Don .............................................................................................. 716

Kelso, DDS, Mark, Norton Sound dental director, Nome, AK ...................... 381

Kennedy, Hon. Edward M., U.S. Senator from Massachusetts .................... 379

Kovaleski, DDS, Tom, director, Southcentral Foundation Dental Program 382

McCain, Hon. John, U.S. Senator from Arizona, chairman, Committee

on Indian Affairs ........................................................................................... 380

Milgrom, DDS, Peter, center director, Professor of Dental Public Sciences

and Health Services, University of Washington, Seattle, WA .................. 750
Page

IV

Prepared statements—Continued

Murray, Hon. Patty, U.S. Senator from Washington .................................... 381

Nash, D.M.D., M.S., Ed.D., David A., professor of pediatric dentistry

in the College of Dentistry at the University of Kentucky in Lexington,

KY (with attachment) ................................................................................... 757

Willard, William R., professor of dental education; professor of pediatric

dentistry, University of Kentucky Medical Center (with attachment) ..... 757

Williard, Dr. Mary ............................................................................................ 784

Additional material submitted for the record:

Letters:

Clark, Robert J., Bristol Bay Area Health Corporation ................................ 788

Dawson, RDH, BS, Katie L., president, American Dental Hygienists’ Association ......................................................................................................... 793

Evans, Robert D. ............................................................................................... 798

Juan-Saunders, Vivian, president, Inter Tribal Council of Arizona, chairwoman, Tohono O’odham Nation (position paper) ..................................... 800

Kaufmann, ND, Andrew J., San Carlos Apache Tribe .................................. 804

Sekiguchi, et al, letter to the Editor, American Journal of Public Health,

November 2005 ............................................................................................. 806

Questions:

From Hon. Orin G. Hatch, U.S. Senator from Utah (no responses at

time of printing) ............................................................................................ 383

Reports:

Intergrated Dental Health Program for Alaska Native Populations, by

Howard Bailit, D.M.D; Tryfon Beazoglou, Ph.D; Amid Ismail, D.D.S.;

and Thomas Kovaleski, D.D.S. .................................................................... 808
(1)

INDIAN HEALTH CARE IMPROVEMENT ACT

THURSDAY, JULY 14, 2005

U.S. SENATE, COMMITTEE ON INDIAN AFFAIRS, MEETING

JOINTLY WITH THE COMMITTEE ON HEALTH, EDU- CATION, LABOR AND PENSIONS

Washington, DC.

The committee met, pursuant to notice, at 10:16 a.m. in room

106 Dirksen Senate Building, Hon. John McCain (chairman of the

Committee on Indian Affairs) and Hon. Michael B. Enzi (chairman

of the Committee on Health, Education, Labor and Pensions), presiding.

Present: Senators McCain, Enzi, Cantwell, Coburn, Dorgan,

Inouye, Isakson, Kennedy, Murkowski, Murray and Reed.

STATEMENT OF HON. MICHAEL B. ENZI, U.S. SENATOR FROM

WYOMING, CHAIRMAN, COMMITTEE ON HEALTH, EDUCATION, LABOR AND PENSIONS

Senator ENZI. I am going to call to order this historic joint meeting of the Committee on Indian Affairs and the Committee on

Health, Education, Labor and Pensions. Today’s hearing will focus

on the state of Indian health care and specifically the Indian

Health Care Improvement Act.

We will be welcoming Senator McCain here shortly, and the rest

of the members of the Indian Affairs Committee to our HELP Committee meeting room. Senator Kennedy and I started a policy of

punctuality and we are continuing that. We will go ahead and

make our comments and then they can make theirs when they arrive.

Earlier this year, Senator McCain did approach me about holding

a joint committee hearing on the state of Indian health care. I immediately accepted, as health care is important, perhaps the most

important issue facing tribes today, in fact, facing all people today.

Today’s hearing will enable us to chart our current progress and

discuss what we can do to increase the services that are available

to address the physical and emotional problems that continue to

plague American Indians and Alaska Natives.

When the Indian Health Care Improvement Act was first signed

into law in 1976, it was written to address the findings of surveys

and studies that indicated that the health status of American Indians and Alaska Natives was far below that of the general population. It continues to be a matter of serious concern that, as the

health status of most Americans continues to rise, the status of
2

American Indians and Alaska Natives has not kept pace with the

general population.

Studies show that American Indians and Alaska Natives die at

a higher rate than other Americans from alcoholism, tuberculosis,

auto accidents, diabetes, homicide and suicide. In addition, a safe

and adequate water supply and waste disposal facilities, something

we all take for granted, is not available in 12 percent of American

Indian and Alaska Native homes, as opposed to 1 percent in the

rest of the Nation.

Several years ago, residents of the Wind River Reservation in

Central Wyoming faced a drinking water shortage that threatened

the health and safety of everybody in the area, so drinking water

was donated to tribal members and local residents. The lack of

these basic services makes life even harsher for these people and

contributes to those already-high death rates. Coming from Wyoming, I know full well the problems we encounter in the effort to

provide quality health care to all people of my home State.

As I noted during my visits to the Wind River Reservation, their

problems are not unique. They have an impact on all those who

live on reservations from coast to coast. We need to take a varied

approach to address each of those problems separately. Clearly,

people of different ages have different problems.

A multifaceted approach to solving each of the problems will require a systematic, as well as financial approach. Local, State and

national governments and agencies must work together with tribal

leaders to focus our resources where they will do the most good.

That kind of approach has the greatest chance of being successful.

I appreciate all the witnesses taking time out of their busy

schedules to be with us today. In addition, of course, I would like

to welcome Richard Brannan, the chairman of the Northern Arapaho Business Council of Fort Washakie, WY. No one knows better

than he does the problems faced by those living on reservations

and by those who rely on the Indian Health Service for their health

care needs. I am very pleased he was able to make the journey and

to share his experiences with us today.

I look forward to his comments and those of the entire list of witnesses. Each of you has a perspective and a point of view to share

that only you can provide. I look forward to hearing a summary of

your prepared remarks so that we can address the underlying

issues during our question and answer session.

To the members of the joint committees, we have a longstanding

tradition on the HELP Committee that opening statements are

made by the Chairman and Ranking Member, and due to the combined number of members of both committees and the fact that we

have three panels and the fact that we begin voting again at 3

p.m., I would respectfully submit or ask that the tradition apply for

today’s hearing, but all members’ full statements will be made a

part of the record, as will all witnesses full statements be made a

part of the record.

In addition, members may use the question and answer period

to make remarks. I did mention that this is an historic situation

of having the two committees that have an intense interest in Indian health working together to come up with some solutions. I

really appreciate Chairman McCain suggesting that, and following
3

through on it. I think this will be the first time that this has actually been done outside of Energy and Water. This is probably an

appropriate place to do it.

[Text of S. 1057 follows:]
4

1

II

109TH CONGRESS

1ST SESSION S. 1057

To amend the Indian Health Care Improvement Act to revise and extend

that Act.

IN THE SENATE OF THE UNITED STATES

MAY 17, 2005

Mr. MCCAIN (for himself and Mr. DORGAN) introduced the following bill;

which was read twice and referred to the Committee on Indian Affairs

A BILL

To amend the Indian Health Care Improvement Act to revise

and extend that Act.

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled,

3 SECTION 1. SHORT TITLE.

4 This Act may be cited as the ‘‘Indian Health Care

5 Improvement Act Amendments of 2005’’.

6 SEC. 2. INDIAN HEALTH CARE IMPROVEMENT ACT AMEND7 ED.

8 (a) IN GENERAL.—The Indian Health Care Improve9 ment Act (25 U.S.C. 1601 et seq.) is amended to read

10 as follows:
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•S 1057 IS

1 ‘‘SECTION 1. SHORT TITLE; TABLE OF CONTENTS.

2 ‘‘(a) SHORT TITLE.—This Act may be cited as the

3 ‘Indian Health Care Improvement Act’.

4 ‘‘(b) TABLE OF CONTENTS.—The table of contents

5 for this Act is as follows:

‘‘Sec. 1. Short title; table of contents.

‘‘Sec. 2. Findings.

‘‘Sec. 3. Declaration of National Indian health policy.

‘‘Sec. 4. Definitions.

‘‘TITLE I—INDIAN HEALTH, HUMAN RESOURCES, AND

DEVELOPMENT

‘‘Sec. 101. Purpose.

‘‘Sec. 102. Health professions recruitment program for Indians.

‘‘Sec. 103. Health professions preparatory scholarship program for Indians.

‘‘Sec. 104. Indian health professions scholarships.

‘‘Sec. 105. American Indians Into Psychology program.

‘‘Sec. 106. Funding for tribes for scholarship programs.

‘‘Sec. 107. Indian Health Service extern programs.

‘‘Sec. 108. Continuing education allowances.

‘‘Sec. 109. Community health representative program.

‘‘Sec. 110. Indian Health Service loan repayment program.

‘‘Sec. 111. Scholarship and Loan Repayment Recovery Fund.

‘‘Sec. 112. Recruitment activities.

‘‘Sec. 113. Indian recruitment and retention program.

‘‘Sec. 114. Advanced training and research.

‘‘Sec. 115. Quentin N. Burdick American Indians Into Nursing program.

‘‘Sec. 116. Tribal cultural orientation.

‘‘Sec. 117. Inmed program.

‘‘Sec. 118. Health training programs of community colleges.

‘‘Sec. 119. Retention bonus.

‘‘Sec. 120. Nursing residency program.

‘‘Sec. 121. Community health aide program for Alaska.

‘‘Sec. 122. Tribal health program administration.

‘‘Sec. 123. Health professional chronic shortage demonstration programs.

‘‘Sec. 124. National Health Service Corps.

‘‘Sec. 125. Substance abuse counselor educational curricula demonstration

programs.

‘‘Sec. 126. Behavioral health training and community education programs.

‘‘Sec. 127. Authorization of appropriations.

‘‘TITLE II—HEALTH SERVICES

‘‘Sec. 201. Indian Health Care Improvement Fund.

‘‘Sec. 202. Catastrophic Health Emergency Fund.

‘‘Sec. 203. Health promotion and disease prevention services.

‘‘Sec. 204. Diabetes prevention, treatment, and control.

‘‘Sec. 205. Shared services for long-term care.
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•S 1057 IS

‘‘Sec. 206. Health services research.

‘‘Sec. 207. Mammography and other cancer screening.

‘‘Sec. 208. Patient travel costs.

‘‘Sec. 209. Epidemiology centers.

‘‘Sec. 210. Comprehensive school health education programs.

‘‘Sec. 211. Indian youth program.

‘‘Sec. 212. Prevention, control, and elimination of communicable and infectious diseases.

‘‘Sec. 213. Authority for provision of other services.

‘‘Sec. 214. Indian women’s health care.

‘‘Sec. 215. Environmental and nuclear health hazards.

‘‘Sec. 216. Arizona as a contract health service delivery area.

‘‘Sec. 216A. North Dakota and South Dakota as a contract health service

delivery area.

‘‘Sec. 217. California contract health services program.

‘‘Sec. 218. California as a contract health service delivery area.

‘‘Sec. 219. Contract health services for the Trenton service area.

‘‘Sec. 220. Programs operated by Indian tribes and tribal organizations.

‘‘Sec. 221. Licensing.

‘‘Sec. 222. Notification of provision of emergency contract health services.

‘‘Sec. 223. Prompt action on payment of claims.

‘‘Sec. 224. Liability for payment.

‘‘Sec. 225. Authorization of appropriations.

‘‘TITLE III—FACILITIES

‘‘Sec. 301. Consultation: construction and renovation of facilities; reports.

‘‘Sec. 302. Sanitation facilities.

‘‘Sec. 303. Preference to Indians and Indian firms.

‘‘Sec. 304. Expenditure of nonservice funds for renovation.

‘‘Sec. 305. Funding for the construction, expansion, and modernization of

small ambulatory care facilities.

‘‘Sec. 306. Indian health care delivery demonstration project.

‘‘Sec. 307. Land transfer.

‘‘Sec. 308. Leases, contracts, and other agreements.

‘‘Sec. 309. Loans, loan guarantees, and loan repayment.

‘‘Sec. 310. Tribal leasing.

‘‘Sec. 311. Indian Health Service/tribal facilities joint venture program.

‘‘Sec. 312. Location of facilities.

‘‘Sec. 313. Maintenance and improvement of health care facilities.

‘‘Sec. 314. Tribal management of Federally owned quarters.

‘‘Sec. 315. Applicability of Buy American Act requirement.

‘‘Sec. 316. Other funding for facilities.

‘‘Sec. 317. Authorization of appropriations.

‘‘TITLE IV—ACCESS TO HEALTH SERVICES

‘‘Sec. 401. Treatment of payments under Social Security Act health care

programs.

‘‘Sec. 402. Grants to and contracts with the Service, Indian tribes, Tribal

Organizations, and Urban Indian Organizations.

‘‘Sec. 403. Reimbursement from certain third parties of costs of health

services.

‘‘Sec. 404. Crediting of reimbursements.

‘‘Sec. 405. Purchasing health care coverage.

‘‘Sec. 406. Sharing arrangements with Federal agencies.
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•S 1057 IS

‘‘Sec. 407. Payor of last resort.

‘‘Sec. 408. Nondiscrimination in qualifications for reimbursement for services.

‘‘Sec. 409. Consultation.

‘‘Sec. 410. State Children’s Health Insurance Program (SCHIP).

‘‘Sec. 411. Social Security Act sanctions.

‘‘Sec. 412. Cost sharing.

‘‘Sec. 413. Treatment under Medicaid managed care.

‘‘Sec. 414. Navajo Nation Medicaid Agency feasibility study.

‘‘Sec. 415. Authorization of appropriations.

‘‘TITLE V—HEALTH SERVICES FOR URBAN INDIANS

‘‘Sec. 501. Purpose.

‘‘Sec. 502. Contracts with, and grants to, Urban Indian Organizations.

‘‘Sec. 503. Contracts and grants for the provision of health care and referral services.

‘‘Sec. 504. Contracts and grants for the determination of unmet health

care needs.

‘‘Sec. 505. Evaluations; renewals.

‘‘Sec. 506. Other contract and grant requirements.

‘‘Sec. 507. Reports and records.

‘‘Sec. 508. Limitation on contract authority.

‘‘Sec. 509. Facilities.

‘‘Sec. 510. Office of Urban Indian Health.

‘‘Sec. 511. Grants for alcohol and substance abuse-related services.

‘‘Sec. 512. Treatment of certain demonstration projects.

‘‘Sec. 513. Urban NIAAA transferred programs.

‘‘Sec. 514. Consultation with Urban Indian Organizations.

‘‘Sec. 515. Federal Tort Claim Act coverage.

‘‘Sec. 516. Urban youth treatment center demonstration.

‘‘Sec. 517. Use of Federal Government facilities and sources of supply.

‘‘Sec. 518. Grants for diabetes prevention, treatment, and control.

‘‘Sec. 519. Community health representatives.

‘‘Sec. 520. Regulations.

‘‘Sec. 521. Eligibility for services.

‘‘Sec. 522. Authorization of appropriations.

‘‘TITLE VI—ORGANIZATIONAL IMPROVEMENTS

‘‘Sec. 601. Establishment of the Indian Health Service as an agency of the

Public Health Service.

‘‘Sec. 602. Automated management information system.

‘‘Sec. 603. Authorization of appropriations.

‘‘TITLE VII—BEHAVIORAL HEALTH PROGRAMS

‘‘Sec. 701. Behavioral health prevention and treatment services.

‘‘Sec. 702. Memoranda of agreement with the Department of the Interior.

‘‘Sec. 703. Comprehensive behavioral health prevention and treatment program.

‘‘Sec. 704. Mental health technician program.

‘‘Sec. 705. Licensing requirement for mental health care workers.

‘‘Sec. 706. Indian women treatment programs.

‘‘Sec. 707. Indian youth program.
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•S 1057 IS

‘‘Sec. 708. Inpatient and community-based mental health facilities design,

construction, and staffing.

‘‘Sec. 709. Training and community education.

‘‘Sec. 710. Behavioral health program.

‘‘Sec. 711. Fetal alcohol disorder funding.

‘‘Sec. 712. Child sexual abuse and prevention treatment programs.

‘‘Sec. 713. Behavioral health research.

‘‘Sec. 714. Definitions.

‘‘Sec. 715. Authorization of appropriations.

‘‘TITLE VIII—MISCELLANEOUS

‘‘Sec. 801. Reports.

‘‘Sec. 802. Regulations.

‘‘Sec. 803. Plan of implementation.

‘‘Sec. 804. Availability of funds.

‘‘Sec. 805. Limitation on use of funds appropriated to the Indian Health

Service.

‘‘Sec. 806. Eligibility of California Indians.

‘‘Sec. 807. Health services for ineligible persons.

‘‘Sec. 808. Reallocation of base resources.

‘‘Sec. 809. Results of demonstration projects.

‘‘Sec. 810. Provision of services in Montana.

‘‘Sec. 811. Moratorium.

‘‘Sec. 812. Tribal employment.

‘‘Sec. 813. Severability provisions.

‘‘Sec. 814. Establishment of National Bipartisan Commission on Indian

Health Care.

‘‘Sec. 815. Appropriations; availability.

‘‘Sec. 816. Authorization of appropriations.

1 ‘‘SEC. 2. FINDINGS.

2 ‘‘Congress makes the following findings:

3 ‘‘(1) Federal health services to maintain and

4 improve the health of the Indians are consonant

5 with and required by the Federal Government’s his6 torical and unique legal relationship with, and re7 sulting responsibility to, the American Indian people.

8 ‘‘(2) A major national goal of the United States

9 is to provide the quantity and quality of health serv10 ices which will permit the health status of Indians

11 to be raised to the highest possible level and to en-
9

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•S 1057 IS

1 courage the maximum participation of Indians in the

2 planning and management of those services.

3 ‘‘(3) Federal health services to Indians have re4 sulted in a reduction in the prevalence and incidence

5 of preventable illnesses among, and unnecessary and

6 premature deaths of, Indians.

7 ‘‘(4) Despite such services, the unmet health

8 needs of the American Indian people are severe and

9 the health status of the Indians is far below that of

10 the general population of the United States.

11 ‘‘SEC. 3. DECLARATION OF NATIONAL INDIAN HEALTH POL12 ICY.

13 ‘‘Congress declares that it is the policy of this Nation,

14 in fulfillment of its special trust responsibilities and legal

15 obligations to Indians—

16 ‘‘(1) to assure the highest possible health status

17 for Indians and to provide all resources necessary to

18 effect that policy;

19 ‘‘(2) to raise the health status of Indians by the

20 year 2010 to at least the levels set forth in the goals

21 contained within the Healthy People 2010 or succes22 sor objectives;

23 ‘‘(3) to the greatest extent possible, to allow In24 dians to set their own health care priorities and es25 tablish goals that reflect their unmet needs;
10

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•S 1057 IS

1 ‘‘(4) to increase the proportion of all degrees in

2 the health professions and allied and associated

3 health professions awarded to Indians so that the

4 proportion of Indian health professionals in each

5 Service Area is raised to at least the level of that of

6 the general population;

7 ‘‘(5) to require meaningful consultation with In8 dian Tribes, Tribal Organizations, and Urban Indian

9 Organizations to implement this Act and the na10 tional policy of Indian self-determination; and

11 ‘‘(6) to provide funding for programs and facili12 ties operated by Indian Tribes and Tribal Organiza13 tions in amounts that are not less than the amounts

14 provided to programs and facilities operated directly

15 by the Service.

16 ‘‘SEC. 4. DEFINITIONS.

17 ‘‘For purposes of this Act:

18 ‘‘(1) The term ‘accredited and accessible’ means

19 on or near a reservation and accredited by a na20 tional or regional organization with accrediting au21 thority.

22 ‘‘(2) The term ‘Area Office’ means an adminis23 trative entity, including a program office, within the

24 Service through which services and funds are pro-
11

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•S 1057 IS

1 vided to the Service Units within a defined geo2 graphic area.

3 ‘‘(3) The term ‘Assistant Secretary’ means the

4 Assistant Secretary of Indian Health.

5 ‘‘(4)(A) The term ‘behavioral health’ means the

6 blending of substance (alcohol, drugs, inhalants, and

7 tobacco) abuse and mental health prevention and

8 treatment, for the purpose of providing comprehen9 sive services.

10 ‘‘(B) The term ‘behavioral health’ includes the

11 joint development of substance abuse and mental

12 health treatment planning and coordinated case

13 management using a multidisciplinary approach.

14 ‘‘(5) The term ‘California Indians’ means those

15 Indians who are eligible for health services of the

16 Service pursuant to section 806.

17 ‘‘(6) The term ‘community college’ means—

18 ‘‘(A) a tribal college or university, or

19 ‘‘(B) a junior or community college.

20 ‘‘(7) The term ‘contract health service’ means

21 health services provided at the expense of the Serv22 ice or a Tribal Health Program by public or private

23 medical providers or hospitals, other than the Serv24 ice Unit or the Tribal Health Program at whose ex25 pense the services are provided.
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•S 1057 IS

1 ‘‘(8) The term ‘Department’ means, unless oth2 erwise designated, the Department of Health and

3 Human Services.

4 ‘‘(9) The term ‘disease prevention’ means the

5 reduction, limitation, and prevention of disease and

6 its complications and reduction in the consequences

7 of disease, including—

8 ‘‘(A) controlling—

9 ‘‘(i) development of diabetes;

10 ‘‘(ii) high blood pressure;

11 ‘‘(iii) infectious agents;

12 ‘‘(iv) injuries;

13 ‘‘(v) occupational hazards and disabil14 ities;

15 ‘‘(vi) sexually transmittable diseases;

16 and

17 ‘‘(vii) toxic agents; and

18 ‘‘(B) providing—

19 ‘‘(i) fluoridation of water; and

20 ‘‘(ii) immunizations.

21 ‘‘(10) The term ‘health profession’ means

22 allopathic medicine, family medicine, internal medi23 cine, pediatrics, geriatric medicine, obstetrics and

24 gynecology, podiatric medicine, nursing, public

25 health nursing, dentistry, psychiatry, osteopathy, op-
13

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•S 1057 IS

1 tometry, pharmacy, psychology, public health, social

2 work, marriage and family therapy, chiropractic

3 medicine, environmental health and engineering, al4 lied health professions, and any other health profes5 sion.

6 ‘‘(11) The term ‘health promotion’ means—

7 ‘‘(A) fostering social, economic, environ8 mental, and personal factors conducive to

9 health, including raising public awareness about

10 health matters and enabling the people to cope

11 with health problems by increasing their knowl12 edge and providing them with valid information;

13 ‘‘(B) encouraging adequate and appro14 priate diet, exercise, and sleep;

15 ‘‘(C) promoting education and work in con16 formity with physical and mental capacity;

17 ‘‘(D) making available suitable housing,

18 safe water, and sanitary facilities;

19 ‘‘(E) improving the physical, economic, cul20 tural, psychological, and social environment;

21 ‘‘(F) promoting adequate opportunity for

22 spiritual, religious, and Traditional Health Care

23 Practices; and

24 ‘‘(G) providing adequate and appropriate

25 programs, including—
14

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•S 1057 IS

1 ‘‘(i) abuse prevention (mental and

2 physical);

3 ‘‘(ii) community health;

4 ‘‘(iii) community safety;

5 ‘‘(iv) consumer health education;

6 ‘‘(v) diet and nutrition;

7 ‘‘(vi) immunization and other preven8 tion of communicable diseases, including

9 HIV/AIDS;

10 ‘‘(vii) environmental health;

11 ‘‘(viii) exercise and physical fitness;

12 ‘‘(ix) avoidance of fetal alcohol dis13 orders;

14 ‘‘(x) first aid and CPR education;

15 ‘‘(xi) human growth and development;

16 ‘‘(xii) injury prevention and personal

17 safety;

18 ‘‘(xiii) behavioral health;

19 ‘‘(xiv) monitoring of disease indicators

20 between health care provider visits,

21 through appropriate means, including

22 Internet-based health care management

23 systems;

24 ‘‘(xv) personal health and wellness

25 practices;
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1 ‘‘(xvi) personal capacity building;

2 ‘‘(xvii) prenatal, pregnancy, and in3 fant care;

4 ‘‘(xviii) psychological well-being;

5 ‘‘(xix) reproductive health and family

6 planning;

7 ‘‘(xx) safe and adequate water;

8 ‘‘(xxi) safe housing, relating to elimi9 nation, reduction, and prevention of con10 taminants that create unhealthy housing

11 conditions;

12 ‘‘(xxii) safe work environments;

13 ‘‘(xxiii) stress control;

14 ‘‘(xxiv) substance abuse;

15 ‘‘(xxv) sanitary facilities;

16 ‘‘(xxvi) sudden infant death syndrome

17 prevention;

18 ‘‘(xxvii) tobacco use cessation and re19 duction;

20 ‘‘(xxviii) violence prevention; and

21 ‘‘(xxix) such other activities identified

22 by the Service, a Tribal Health Program,

23 or an Urban Indian Organization, to pro24 mote achievement of any of the objectives

25 described in section 3(2).
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1 ‘‘(12) The term ‘Indian’, unless otherwise des2 ignated, means any person who is a member of an

3 Indian tribe or is eligible for health services under

4 section 806, except that, for the purpose of sections

5 102 and 103, the term also means any individual

6 who—

7 ‘‘(A)(i) irrespective of whether the individ8 ual lives on or near a reservation, is a member

9 of a tribe, band, or other organized group of In10 dians, including those tribes, bands, or groups

11 terminated since 1940 and those recognized

12 now or in the future by the State in which they

13 reside; or

14 ‘‘(ii) is a descendant, in the first or second

15 degree, of any such member;

16 ‘‘(B) is an Eskimo or Aleut or other Alas17 ka Native;

18 ‘‘(C) is considered by the Secretary of the

19 Interior to be an Indian for any purpose; or

20 ‘‘(D) is determined be an Indian under

21 regulations promulgated by the Secretary.

22 ‘‘(13) The term ‘Indian Health Program’

23 means—

24 ‘‘(A) any health program administered di25 rectly by the Service;
17

14

•S 1057 IS

1 ‘‘(B) any Tribal Health Program; or

2 ‘‘(C) any Indian Tribe or Tribal Organiza3 tion to which the Secretary provides funding

4 pursuant to section 23 of the Act of April 30,

5 1908 (25 U.S.C. 47), commonly known as the

6 ‘Buy Indian Act’.

7 ‘‘(14) The term ‘Indian Tribe’ has the meaning

8 given the term in the Indian Self-Determination and

9 Education Assistance Act (25 U.S.C. 450 et seq.).

10 ‘‘(15) The term ‘junior or community college’

11 has the meaning given the term by section 312(e) of

12 the Higher Education Act of 1965 (20 U.S.C.

13 1058(e)).

14 ‘‘(16) The term ‘reservation’ means any feder15 ally recognized Indian Tribe’s reservation, Pueblo, or

16 colony, including former reservations in Oklahoma,

17 Indian allotments, and Alaska Native Regions estab18 lished pursuant to the Alaska Native Claims Settle19 ment Act (25 U.S.C. 1601 et seq.).

20 ‘‘(17) The term ‘Secretary’, unless otherwise

21 designated, means the Secretary of Health and

22 Human Services.

23 ‘‘(18) The term ‘Service’ means the Indian

24 Health Service.
18

15

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1 ‘‘(19) The term ‘Service Area’ means the geo2 graphical area served by each Area Office.

3 ‘‘(20) The term ‘Service Unit’ means an admin4 istrative entity of the Service, or a Tribal Health

5 Program through which services are provided, di6 rectly or by contract, to eligible Indians within a de7 fined geographic area.

8 ‘‘(21) The term ‘telehealth’ has the meaning

9 given the term in section 330K(a) of the Public

10 Health Service Act (42 U.S.C. 254c–16(a)).

11 ‘‘(22) The term ‘telemedicine’ means a tele12 communications link to an end user through the use

13 of eligible equipment that electronically links health

14 professionals or patients and health professionals at

15 separate sites in order to exchange health care infor16 mation in audio, video, graphic, or other format for

17 the purpose of providing improved health care serv18 ices.

19 ‘‘(23) The term ‘Traditional Health Care Prac20 tices’ means the application by Native healing prac21 titioners of the Native healing sciences (as opposed

22 or in contradistinction to Western healing sciences)

23 which embody the influences or forces of innate

24 Tribal discovery, history, description, explanation

25 and knowledge of the states of wellness and illness
19

16

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1 and which call upon these influences or forces, in2 cluding physical, mental, and spiritual forces in the

3 promotion, restoration, preservation, and mainte4 nance of health, well-being, and life’s harmony.

5 ‘‘(24) The term ‘tribal college or university’ has

6 the meaning given the term in section 316(b)(3) of

7 the Higher Education Act (20 U.S.C. 1059c(b)(3)).

8 ‘‘(25) The term ‘Tribal Health Program’ means

9 an Indian Tribe or Tribal Organization that oper10 ates any health program, service, function, activity,

11 or facility funded, in whole or part, by the Service

12 through, or provided for in, a contract or compact

13 with the Service under the Indian Self-Determina14 tion and Education Assistance Act (25 U.S.C. 450

15 et seq.).

16 ‘‘(26) The term ‘Tribal Organization’ has the

17 meaning given the term in the Indian Self-Deter18 mination and Education Assistance Act (25 U.S.C.

19 450 et seq.).

20 ‘‘(27) The term ‘Urban Center’ means any com21 munity which has a sufficient Urban Indian popu22 lation with unmet health needs to warrant assistance

23 under title V of this Act, as determined by the Sec24 retary.
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1 ‘‘(28) The term ‘Urban Indian’ means any indi2 vidual who resides in an Urban Center and who

3 meets 1 or more of the following criteria:

4 ‘‘(A) Irrespective of whether the individual

5 lives on or near a reservation, the individual is

6 a member of a tribe, band, or other organized

7 group of Indians, including those tribes, bands,

8 or groups terminated since 1940 and those

9 tribes, bands, or groups that are recognized by

10 the States in which they reside, or who is a de11 scendant in the first or second degree of any

12 such member.

13 ‘‘(B) The individual is an Eskimo, Aleut,

14 or other Alaskan Native.

15 ‘‘(C) The individual is considered by the

16 Secretary of the Interior to be an Indian for

17 any purpose.

18 ‘‘(D) The individual is determined to be an

19 Indian under regulations promulgated by the

20 Secretary.

21 ‘‘(29) The term ‘Urban Indian Organization’

22 means a nonprofit corporate body that (A) is situ23 ated in an Urban Center; (B) is governed by an

24 Urban Indian-controlled board of directors; (C) pro25 vides for the participation of all interested Indian
21

18

•S 1057 IS

1 groups and individuals; and (D) is capable of legally

2 cooperating with other public and private entities for

3 the purpose of performing the activities described in

4 section 503(a).

5 ‘‘TITLE I—INDIAN HEALTH,

6 HUMAN RESOURCES, AND DE7 VELOPMENT

8 ‘‘SEC. 101. PURPOSE.

9 ‘‘The purpose of this title is to increase, to the maxi10 mum extent feasible, the number of Indians entering the

11 health professions and providing health services, and to

12 assure an optimum supply of health professionals to the

13 Indian Health Programs and Urban Indian Organizations

14 involved in the provision of health services to Indians.

15 ‘‘SEC. 102. HEALTH PROFESSIONS RECRUITMENT PROGRAM

16 FOR INDIANS.

17 ‘‘(a) IN GENERAL.—The Secretary, acting through

18 the Service, shall make grants to public or nonprofit pri19 vate health or educational entities, Tribal Health Pro20 grams, or Urban Indian Organizations to assist such enti21 ties in meeting the costs of—

22 ‘‘(1) identifying Indians with a potential for

23 education or training in the health professions and

24 encouraging and assisting them—
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19

•S 1057 IS

1 ‘‘(A) to enroll in courses of study in such

2 health professions; or

3 ‘‘(B) if they are not qualified to enroll in

4 any such courses of study, to undertake such

5 postsecondary education or training as may be

6 required to qualify them for enrollment;

7 ‘‘(2) publicizing existing sources of financial aid

8 available to Indians enrolled in any course of study

9 referred to in paragraph (1) or who are undertaking

10 training necessary to qualify them to enroll in any

11 such course of study; or

12 ‘‘(3) establishing other programs which the Sec13 retary determines will enhance and facilitate the en14 rollment of Indians in, and the subsequent pursuit

15 and completion by them of, courses of study referred

16 to in paragraph (1).

17 ‘‘(b) FUNDING.—

18 ‘‘(1) APPLICATION.—The Secretary shall not

19 make a grant under this section unless an applica20 tion has been submitted to, and approved by, the

21 Secretary. Such application shall be in such form,

22 submitted in such manner, and contain such infor23 mation, as the Secretary shall by regulation pre24 scribe pursuant to this Act. The Secretary shall give
23

20

•S 1057 IS

1 a preference to applications submitted by Tribal

2 Health Programs or Urban Indian Organizations.

3 ‘‘(2) AMOUNT OF FUNDS; PAYMENT.—The

4 amount of a grant under this section shall be deter5 mined by the Secretary. Payments pursuant to this

6 section may be made in advance or by way of reim7 bursement, and at such intervals and on such condi8 tions as provided for in regulations issued pursuant

9 to this Act. To the extent not otherwise prohibited

10 by law, funding commitments shall be for 3 years,

11 as provided in regulations issued pursuant to this

12 Act.

13 ‘‘SEC. 103. HEALTH PROFESSIONS PREPARATORY SCHOL14 ARSHIP PROGRAM FOR INDIANS.

15 ‘‘(a) SCHOLARSHIPS AUTHORIZED.—The Secretary,

16 acting through the Service, shall provide scholarship

17 grants to Indians who—

18 ‘‘(1) have successfully completed their high

19 school education or high school equivalency; and

20 ‘‘(2) have demonstrated the potential to suc21 cessfully complete courses of study in the health pro22 fessions.

23 ‘‘(b) PURPOSES.—Scholarships provided pursuant to

24 this section shall be for the following purposes:
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21

•S 1057 IS

1 ‘‘(1) Compensatory preprofessional education of

2 any recipient, such scholarship not to exceed 2 years

3 on a full-time basis (or the part-time equivalent

4 thereof, as determined by the Secretary pursuant to

5 regulations issued under this Act).

6 ‘‘(2) Pregraduate education of any recipient

7 leading to a baccalaureate degree in an approved

8 course of study preparatory to a field of study in a

9 health profession, such scholarship not to exceed 4

10 years. An extension of up to 2 years (or the part11 time equivalent thereof, as determined by the Sec12 retary pursuant to regulations issued pursuant to

13 this Act) may be approved.

14 ‘‘(c) OTHER CONDITIONS.—Scholarships under this

15 section—

16 ‘‘(1) may cover costs of tuition, books, trans17 portation, board, and other necessary related ex18 penses of a recipient while attending school;

19 ‘‘(2) shall not be denied solely on the basis of

20 the applicant’s scholastic achievement if such appli21 cant has been admitted to, or maintained good

22 standing at, an accredited institution; and

23 ‘‘(3) shall not be denied solely by reason of such

24 applicant’s eligibility for assistance or benefits under

25 any other Federal program.
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22

•S 1057 IS

1 ‘‘SEC. 104. INDIAN HEALTH PROFESSIONS SCHOLARSHIPS.

2 ‘‘(a) IN GENERAL.—

3 ‘‘(1) AUTHORITY.—The Secretary, acting

4 through the Service, shall make scholarship grants

5 to Indians who are enrolled full or part time in ac6 credited schools pursuing courses of study in the

7 health professions. Such scholarships shall be des8 ignated Indian Health Scholarships and shall be

9 made in accordance with section 338A of the Public

10 Health Services Act (42 U.S.C. 2541), except as

11 provided in subsection (b) of this section.

12 ‘‘(2) ALLOCATION BY FORMULA.—Except as

13 provided in paragraph (3), the funding authorized

14 by this section shall be allocated by Service Area by

15 a formula developed in consultation with Indian

16 Tribes, Tribal Organizations, and Urban Indian Or17 ganizations. Such formula shall consider the human

18 resource development needs in each Service Area.

19 ‘‘(3) CONTINUITY OF PRIOR SCHOLARSHIPS.—

20 Paragraph (2) shall not apply with respect to indi21 vidual recipients of scholarships provided under this

22 section (as in effect 1 day prior to the date of enact23 ment of the Indian Health Care Improvement Act

24 Amendments of 2005) until such time as the individ25 ual completes the course of study that is supported

26 through such scholarship.
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23

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1 ‘‘(4) CERTAIN DELEGATION NOT ALLOWED.—

2 The administration of this section shall be a respon3 sibility of the Assistant Secretary and shall not be

4 delegated in a contract or compact under the Indian

5 Self-Determination and Education Assistance Act

6 (25 U.S.C. 450 et seq.).

7 ‘‘(b) ACTIVE DUTY SERVICE OBLIGATION.—

8 ‘‘(1) OBLIGATION MET.—The active duty serv9 ice obligation under a written contract with the Sec10 retary under section 338A of the Public Health

11 Service Act (42 U.S.C. 254l) that an Indian has en12 tered into under that section shall, if that individual

13 is a recipient of an Indian Health Scholarship, be

14 met in full-time practice on an equivalent year-for15 year obligation, by service in one or more of the fol16 lowing:

17 ‘‘(A) In an Indian Health Program.

18 ‘‘(B) In a program assisted under title V

19 of this Act.

20 ‘‘(C) In the private practice of the applica21 ble profession if, as determined by the Sec22 retary, in accordance with guidelines promul23 gated by the Secretary, such practice is situated

24 in a physician or other health professional
27

24

•S 1057 IS

1 shortage area and addresses the health care

2 needs of a substantial number of Indians.

3 ‘‘(2) OBLIGATION DEFERRED.—At the request

4 of any individual who has entered into a contract re5 ferred to in paragraph (1) and who receives a degree

6 in medicine (including osteopathic or allopathic med7 icine), dentistry, optometry, podiatry, or pharmacy,

8 the Secretary shall defer the active duty service obli9 gation of that individual under that contract, in

10 order that such individual may complete any intern11 ship, residency, or other advanced clinical training

12 that is required for the practice of that health pro13 fession, for an appropriate period (in years, as deter14 mined by the Secretary), subject to the following

15 conditions:

16 ‘‘(A) No period of internship, residency, or

17 other advanced clinical training shall be counted

18 as satisfying any period of obligated service

19 under this subsection.

20 ‘‘(B) The active duty service obligation of

21 that individual shall commence not later than

22 90 days after the completion of that advanced

23 clinical training (or by a date specified by the

24 Secretary).
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25

•S 1057 IS

1 ‘‘(C) The active duty service obligation will

2 be served in the health profession of that indi3 vidual in a manner consistent with paragraph

4 (1).

5 ‘‘(D) A recipient of a scholarship under

6 this section may, at the election of the recipient,

7 meet the active duty service obligation described

8 in paragraph (1) by service in a program speci9 fied under that paragraph that—

10 ‘‘(i) is located on the reservation of

11 the Indian Tribe in which the recipient is

12 enrolled; or

13 ‘‘(ii) serves the Indian Tribe in which

14 the recipient is enrolled.

15 ‘‘(3) PRIORITY WHEN MAKING ASSIGNMENTS.—

16 Subject to paragraph (2), the Secretary, in making

17 assignments of Indian Health Scholarship recipients

18 required to meet the active duty service obligation

19 described in paragraph (1), shall give priority to as20 signing individuals to service in those programs

21 specified in paragraph (1) that have a need for

22 health professionals to provide health care services

23 as a result of individuals having breached contracts

24 entered into under this section.
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26

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1 ‘‘(c) PART-TIME STUDENTS.—In the case of an indi2 vidual receiving a scholarship under this section who is

3 enrolled part time in an approved course of study—

4 ‘‘(1) such scholarship shall be for a period of

5 years not to exceed the part-time equivalent of 4

6 years, as determined by the Area Office;

7 ‘‘(2) the period of obligated service described in

8 subsection (b)(1) shall be equal to the greater of—

9 ‘‘(A) the part-time equivalent of 1 year for

10 each year for which the individual was provided

11 a scholarship (as determined by the Area Of12 fice); or

13 ‘‘(B) 2 years; and

14 ‘‘(3) the amount of the monthly stipend speci15 fied in section 338A(g)(1)(B) of the Public Health

16 Service Act (42 U.S.C. 254l(g)(1)(B)) shall be re17 duced pro rata (as determined by the Secretary)

18 based on the number of hours such student is en19 rolled.

20 ‘‘(d) BREACH OF CONTRACT.—

21 ‘‘(1) SPECIFIED BREACHES.—An individual

22 shall be liable to the United States for the amount

23 which has been paid to the individual, or on behalf

24 of the individual, under a contract entered into with

25 the Secretary under this section on or after the date
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27

•S 1057 IS

1 of enactment of the Indian Health Care Improve2 ment Act Amendments of 2005 if that individual—

3 ‘‘(A) fails to maintain an acceptable level

4 of academic standing in the educational institu5 tion in which he or she is enrolled (such level

6 determined by the educational institution under

7 regulations of the Secretary);

8 ‘‘(B) is dismissed from such educational

9 institution for disciplinary reasons;

10 ‘‘(C) voluntarily terminates the training in

11 such an educational institution for which he or

12 she is provided a scholarship under such con13 tract before the completion of such training; or

14 ‘‘(D) fails to accept payment, or instructs

15 the educational institution in which he or she is

16 enrolled not to accept payment, in whole or in

17 part, of a scholarship under such contract, in

18 lieu of any service obligation arising under such

19 contract.

20 ‘‘(2) OTHER BREACHES.—If for any reason not

21 specified in paragraph (1) an individual breaches a

22 written contract by failing either to begin such indi23 vidual’s service obligation required under such con24 tract or to complete such service obligation, the

25 United States shall be entitled to recover from the
31

28

•S 1057 IS

1 individual an amount determined in accordance with

2 the formula specified in subsection (l) of section 110

3 in the manner provided for in such subsection.

4 ‘‘(3) CANCELLATION UPON DEATH OF RECIPI5 ENT.—Upon the death of an individual who receives

6 an Indian Health Scholarship, any outstanding obli7 gation of that individual for service or payment that

8 relates to that scholarship shall be canceled.

9 ‘‘(4) WAIVERS AND SUSPENSIONS.—The Sec10 retary shall provide for the partial or total waiver or

11 suspension of any obligation of service or payment of

12 a recipient of an Indian Health Scholarship if the

13 Secretary, in consultation with the affected Area Of14 fice, Indian Tribes, Tribal Organizations, and Urban

15 Indian Organizations, determines that—

16 ‘‘(A) it is not possible for the recipient to

17 meet that obligation or make that payment;

18 ‘‘(B) requiring that recipient to meet that

19 obligation or make that payment would result

20 in extreme hardship to the recipient; or

21 ‘‘(C) the enforcement of the requirement to

22 meet the obligation or make the payment would

23 be unconscionable.

24 ‘‘(5) EXTREME HARDSHIP.—Notwithstanding

25 any other provision of law, in any case of extreme
32

29

•S 1057 IS

1 hardship or for other good cause shown, the Sec2 retary may waive, in whole or in part, the right of

3 the United States to recover funds made available

4 under this section.

5 ‘‘(6) BANKRUPTCY.—Notwithstanding any

6 other provision of law, with respect to a recipient of

7 an Indian Health Scholarship, no obligation for pay8 ment may be released by a discharge in bankruptcy

9 under title 11, United States Code, unless that dis10 charge is granted after the expiration of the 5-year

11 period beginning on the initial date on which that

12 payment is due, and only if the bankruptcy court

13 finds that the nondischarge of the obligation would

14 be unconscionable.

15 ‘‘SEC. 105. AMERICAN INDIANS INTO PSYCHOLOGY PRO16 GRAM.

17 ‘‘(a) GRANTS AUTHORIZED.—The Secretary, acting

18 through the Service, shall make grants to at least 3 col19 leges and universities for the purpose of developing and

20 maintaining Indian psychology career recruitment pro21 grams as a means of encouraging Indians to enter the

22 mental health field. These programs shall be located at

23 various locations throughout the country to maximize their

24 availability to Indian students and new programs shall be

25 established in different locations from time to time.
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30

•S 1057 IS

1 ‘‘(b) QUENTIN N. BURDICK PROGRAM GRANT.—The

2 Secretary shall provide a grant authorized under sub3 section (a) to develop and maintain a program at the Uni4 versity of North Dakota to be known as the ‘Quentin N.

5 Burdick American Indians Into Psychology Program’.

6 Such program shall, to the maximum extent feasible, co7 ordinate with the Quentin N. Burdick Indian Health Pro8 grams authorized under section 117(b), the Quentin N.

9 Burdick American Indians Into Nursing Program author10 ized under section 115(e), and existing university research

11 and communications networks.

12 ‘‘(c) REGULATIONS.—The Secretary shall issue regu13 lations pursuant to this Act for the competitive awarding

14 of grants provided under this section.

15 ‘‘(d) CONDITIONS OF GRANT.—Applicants under this

16 section shall agree to provide a program which, at a

17 minimum—

18 ‘‘(1) provides outreach and recruitment for

19 health professions to Indian communities including

20 elementary, secondary, and accredited and accessible

21 community colleges that will be served by the pro22 gram;

23 ‘‘(2) incorporates a program advisory board

24 comprised of representatives from the tribes and

25 communities that will be served by the program;
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31

•S 1057 IS

1 ‘‘(3) provides summer enrichment programs to

2 expose Indian students to the various fields of psy3 chology through research, clinical, and experimental

4 activities;

5 ‘‘(4) provides stipends to undergraduate and

6 graduate students to pursue a career in psychology;

7 ‘‘(5) develops affiliation agreements with tribal

8 colleges and universities, the Service, university af9 filiated programs, and other appropriate accredited

10 and accessible entities to enhance the education of

11 Indian students;

12 ‘‘(6) to the maximum extent feasible, uses exist13 ing university tutoring, counseling, and student sup14 port services; and

15 ‘‘(7) to the maximum extent feasible, employs

16 qualified Indians in the program.

17 ‘‘(e) ACTIVE DUTY SERVICE REQUIREMENT.—The

18 active duty service obligation prescribed under section

19 338C of the Public Health Service Act (42 U.S.C. 254m)

20 shall be met by each graduate who receives a stipend de21 scribed in subsection (d)(4) that is funded under this sec22 tion. Such obligation shall be met by service—

23 ‘‘(1) in an Indian Health Program;

24 ‘‘(2) in a program assisted under title V of this

25 Act; or
35

32

•S 1057 IS

1 ‘‘(3) in the private practice of psychology if, as

2 determined by the Secretary, in accordance with

3 guidelines promulgated by the Secretary, such prac4 tice is situated in a physician or other health profes5 sional shortage area and addresses the health care

6 needs of a substantial number of Indians.

7 ‘‘SEC. 106. FUNDING FOR TRIBES FOR SCHOLARSHIP PRO8 GRAMS.

9 ‘‘(a) IN GENERAL.—

10 ‘‘(1) GRANTS AUTHORIZED.—The Secretary,

11 acting through the Service, shall make grants to

12 Tribal Health Programs for the purpose of providing

13 scholarships for Indians to serve as health profes14 sionals in Indian communities.

15 ‘‘(2) AMOUNT.—Amounts available under para16 graph (1) for any fiscal year shall not exceed 5 per17 cent of the amounts available for each fiscal year for

18 Indian Health Scholarships under section 104.

19 ‘‘(3) APPLICATION.—An application for a grant

20 under paragraph (1) shall be in such form and con21 tain such agreements, assurances, and information

22 as consistent with this section.

23 ‘‘(b) REQUIREMENTS.—

24 ‘‘(1) IN GENERAL.—A Tribal Health Program

25 receiving a grant under subsection (a) shall provide
36

33

•S 1057 IS

1 scholarships to Indians in accordance with the re2 quirements of this section.

3 ‘‘(2) COSTS.—With respect to costs of providing

4 any scholarship pursuant to subsection (a)—

5 ‘‘(A) 80 percent of the costs of the scholar6 ship shall be paid from the funds made avail7 able pursuant to subsection (a)(1) provided to

8 the Tribal Health Program; and

9 ‘‘(B) 20 percent of such costs may be paid

10 from any other source of funds.

11 ‘‘(c) COURSE OF STUDY.—A Tribal Health Program

12 shall provide scholarships under this section only to Indi13 ans enrolled or accepted for enrollment in a course of

14 study (approved by the Secretary) in one of the health pro15 fessions contemplated by this Act.

16 ‘‘(d) CONTRACT.—In providing scholarships under

17 subsection (b), the Secretary and the Tribal Health Pro18 gram shall enter into a written contract with each recipi19 ent of such scholarship. Such contract shall—

20 ‘‘(1) obligate such recipient to provide service in

21 an Indian Health Program or Urban Indian Organi22 zation, in the same Service Area where the Tribal

23 Health Program providing the scholarship is located,

24 for—
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34

•S 1057 IS

1 ‘‘(A) a number of years for which the

2 scholarship is provided (or the part-time equiva3 lent thereof, as determined by the Secretary),

4 or for a period of 2 years, whichever period is

5 greater; or

6 ‘‘(B) such greater period of time as the re7 cipient and the Tribal Health Program may

8 agree;

9 ‘‘(2) provide that the amount of the

10 scholarship—

11 ‘‘(A) may only be expended for—

12 ‘‘(i) tuition expenses, other reasonable

13 educational expenses, and reasonable living

14 expenses incurred in attendance at the

15 educational institution; and

16 ‘‘(ii) payment to the recipient of a

17 monthly stipend of not more than the

18 amount authorized by section 338(g)(1)(B)

19 of the Public Health Service Act (42

20 U.S.C. 254m(g)(1)(B)), with such amount

21 to be reduced pro rata (as determined by

22 the Secretary) based on the number of

23 hours such student is enrolled, and not to

24 exceed, for any year of attendance for

25 which the scholarship is provided, the total
38

35

•S 1057 IS

1 amount required for the year for the pur2 poses authorized in this clause; and

3 ‘‘(B) may not exceed, for any year of at4 tendance for which the scholarship is provided,

5 the total amount required for the year for the

6 purposes authorized in subparagraph (A);

7 ‘‘(3) require the recipient of such scholarship to

8 maintain an acceptable level of academic standing as

9 determined by the educational institution in accord10 ance with regulations issued pursuant to this Act;

11 and

12 ‘‘(4) require the recipient of such scholarship to

13 meet the educational and licensure requirements ap14 propriate to each health profession.

15 ‘‘(e) BREACH OF CONTRACT.—

16 ‘‘(1) SPECIFIC BREACHES.—An individual who

17 has entered into a written contract with the Sec18 retary and a Tribal Health Program under sub19 section (d) shall be liable to the United States for

20 the Federal share of the amount which has been

21 paid to him or her, or on his or her behalf, under

22 the contract if that individual—

23 ‘‘(A) fails to maintain an acceptable level

24 of academic standing in the educational institu25 tion in which he or she is enrolled (such level
39

36

•S 1057 IS

1 as determined by the educational institution

2 under regulations of the Secretary);

3 ‘‘(B) is dismissed from such educational

4 institution for disciplinary reasons;

5 ‘‘(C) voluntarily terminates the training in

6 such an educational institution for which he or

7 she is provided a scholarship under such con8 tract before the completion of such training; or

9 ‘‘(D) fails to accept payment, or instructs

10 the educational institution in which he or she is

11 enrolled not to accept payment, in whole or in

12 part, of a scholarship under such contract, in

13 lieu of any service obligation arising under such

14 contract.

15 ‘‘(2) OTHER BREACHES.—If for any reason not

16 specified in paragraph (1), an individual breaches a

17 written contract by failing to either begin such indi18 vidual’s service obligation required under such con19 tract or to complete such service obligation, the

20 United States shall be entitled to recover from the

21 individual an amount determined in accordance with

22 the formula specified in subsection (l) of section 110

23 in the manner provided for in such subsection.

24 ‘‘(3) CANCELLATION UPON DEATH OF RECIPI25 ENT.—Upon the death of an individual who receives
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1 an Indian Health Scholarship, any outstanding obli2 gation of that individual for service or payment that

3 relates to that scholarship shall be canceled.

4 ‘‘(4) INFORMATION.—The Secretary may carry

5 out this subsection on the basis of information re6 ceived from Tribal Health Programs involved or on

7 the basis of information collected through such other

8 means as the Secretary deems appropriate.

9 ‘‘(f) RELATION TO SOCIAL SECURITY ACT.—The re10 cipient of a scholarship under this section shall agree, in

11 providing health care pursuant to the requirements

12 herein—

13 ‘‘(1) not to discriminate against an individual

14 seeking care on the basis of the ability of the indi15 vidual to pay for such care or on the basis that pay16 ment for such care will be made pursuant to a pro17 gram established in title XVIII of the Social Secu18 rity Act or pursuant to the programs established in

19 title XIX or title XXI of such Act; and

20 ‘‘(2) to accept assignment under section

21 1842(b)(3)(B)(ii) of the Social Security Act for all

22 services for which payment may be made under part

23 B of title XVIII of such Act, and to enter into an

24 appropriate agreement with the State agency that

25 administers the State plan for medical assistance
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•S 1057 IS

1 under title XIX, or the State child health plan under

2 title XXI, of such Act to provide service to individ3 uals entitled to medical assistance or child health as4 sistance, respectively, under the plan.

5 ‘‘(g) CONTINUANCE OF FUNDING.—The Secretary

6 shall make payments under this section to a Tribal Health

7 Program for any fiscal year subsequent to the first fiscal

8 year of such payments unless the Secretary determines

9 that, for the immediately preceding fiscal year, the Tribal

10 Health Program has not complied with the requirements

11 of this section.

12 ‘‘SEC. 107. INDIAN HEALTH SERVICE EXTERN PROGRAMS.

13 ‘‘(a) EMPLOYMENT PREFERENCE.—Any individual

14 who receives a scholarship pursuant to section 104 or 106

15 shall be given preference for employment in the Service,

16 or may be employed by a Tribal Health Program or an

17 Urban Indian Organization, or other agencies of the De18 partment as available, during any nonacademic period of

19 the year.

20 ‘‘(b) NOT COUNTED TOWARD ACTIVE DUTY SERVICE

21 OBLIGATION.—Periods of employment pursuant to this

22 subsection shall not be counted in determining fulfillment

23 of the service obligation incurred as a condition of the

24 scholarship.
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1 ‘‘(c) TIMING; LENGTH OF EMPLOYMENT.—Any indi2 vidual enrolled in a program, including a high school pro3 gram, authorized under section 102(a) may be employed

4 by the Service or by a Tribal Health Program or an Urban

5 Indian Organization during any nonacademic period of the

6 year. Any such employment shall not exceed 120 days dur7 ing any calendar year.

8 ‘‘(d) NONAPPLICABILITY OF COMPETITIVE PERSON9 NEL SYSTEM.—Any employment pursuant to this section

10 shall be made without regard to any competitive personnel

11 system or agency personnel limitation and to a position

12 which will enable the individual so employed to receive

13 practical experience in the health profession in which he

14 or she is engaged in study. Any individual so employed

15 shall receive payment for his or her services comparable

16 to the salary he or she would receive if he or she were

17 employed in the competitive system. Any individual so em18 ployed shall not be counted against any employment ceil19 ing affecting the Service or the Department.

20 ‘‘SEC. 108. CONTINUING EDUCATION ALLOWANCES.

21 ‘‘In order to encourage health professionals, including

22 community health representatives and emergency medical

23 technicians, to join or continue in an Indian Health Pro24 gram or an Urban Indian Organization and to provide

25 their services in the rural and remote areas where a sig-
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•S 1057 IS

1 nificant portion of Indians reside, the Secretary, acting

2 through the Service, may provide allowances to health pro3 fessionals employed in an Indian Health Program or an

4 Urban Indian Organization to enable them for a period

5 of time each year prescribed by regulation of the Secretary

6 to take leave of their duty stations for professional con7 sultation and refresher training courses.

8 ‘‘SEC. 109. COMMUNITY HEALTH REPRESENTATIVE PRO9 GRAM.

10 ‘‘(a) IN GENERAL.—Under the authority of the Act

11 of November 2, 1921 (25 U.S.C. 13) (commonly known

12 as the ‘Snyder Act’), the Secretary, acting through the

13 Service, shall maintain a Community Health Representa14 tive Program under which Indian Health Programs—

15 ‘‘(1) provide for the training of Indians as com16 munity health representatives; and

17 ‘‘(2) use such community health representatives

18 in the provision of health care, health promotion,

19 and disease prevention services to Indian commu20 nities.

21 ‘‘(b) DUTIES.—The Community Health Representa22 tive Program of the Service, shall—

23 ‘‘(1) provide a high standard of training for

24 community health representatives to ensure that the

25 community health representatives provide quality
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1 health care, health promotion, and disease preven2 tion services to the Indian communities served by

3 the Program;

4 ‘‘(2) in order to provide such training, develop

5 and maintain a curriculum that—

6 ‘‘(A) combines education in the theory of

7 health care with supervised practical experience

8 in the provision of health care; and

9 ‘‘(B) provides instruction and practical ex10 perience in health promotion and disease pre11 vention activities, with appropriate consider12 ation given to lifestyle factors that have an im13 pact on Indian health status, such as alcohol14 ism, family dysfunction, and poverty;

15 ‘‘(3) maintain a system which identifies the

16 needs of community health representatives for con17 tinuing education in health care, health promotion,

18 and disease prevention and develop programs that

19 meet the needs for continuing education;

20 ‘‘(4) maintain a system that provides close su21 pervision of Community Health Representatives;

22 ‘‘(5) maintain a system under which the work

23 of Community Health Representatives is reviewed

24 and evaluated; and
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1 ‘‘(6) promote Traditional Health Care Practices

2 of the Indian Tribes served consistent with the Serv3 ice standards for the provision of health care, health

4 promotion, and disease prevention.

5 ‘‘SEC. 110. INDIAN HEALTH SERVICE LOAN REPAYMENT

6 PROGRAM.

7 ‘‘(a) ESTABLISHMENT.—The Secretary, acting

8 through the Service, shall establish and administer a pro9 gram to be known as the Service Loan Repayment Pro10 gram (hereinafter referred to as the ‘Loan Repayment

11 Program’) in order to ensure an adequate supply of

12 trained health professionals necessary to maintain accredi13 tation of, and provide health care services to Indians

14 through, Indian Health Programs and Urban Indian Or15 ganizations.

16 ‘‘(b) ELIGIBLE INDIVIDUALS.—To be eligible to par17 ticipate in the Loan Repayment Program, an individual

18 must—

19 ‘‘(1)(A) be enrolled—

20 ‘‘(i) in a course of study or program in an

21 accredited educational institution (as deter22 mined by the Secretary under section

23 338B(b)(1)(c)(i) of the Public Health Service

24 Act (42 U.S.C. 254l–1(b)(1)(c)(i))) and be

25 scheduled to complete such course of study in
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1 the same year such individual applies to partici2 pate in such program; or

3 ‘‘(ii) in an approved graduate training pro4 gram in a health profession; or

5 ‘‘(B) have—

6 ‘‘(i) a degree in a health profession; and

7 ‘‘(ii) a license to practice a health profes8 sion;

9 ‘‘(2)(A) be eligible for, or hold, an appointment

10 as a commissioned officer in the Regular or Reserve

11 Corps of the Public Health Service;

12 ‘‘(B) be eligible for selection for civilian service

13 in the Regular or Reserve Corps of the Public

14 Health Service;

15 ‘‘(C) meet the professional standards for civil

16 service employment in the Service; or

17 ‘‘(D) be employed in an Indian Health Program

18 or Urban Indian Organization without a service obli19 gation; and

20 ‘‘(3) submit to the Secretary an application for

21 a contract described in subsection (e).

22 ‘‘(c) APPLICATION.—

23 ‘‘(1) INFORMATION TO BE INCLUDED WITH

24 FORMS.—In disseminating application forms and

25 contract forms to individuals desiring to participate
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•S 1057 IS

1 in the Loan Repayment Program, the Secretary

2 shall include with such forms a fair summary of the

3 rights and liabilities of an individual whose applica4 tion is approved (and whose contract is accepted) by

5 the Secretary, including in the summary a clear ex6 planation of the damages to which the United States

7 is entitled under subsection (l) in the case of the in8 dividual’s breach of contract. The Secretary shall

9 provide such individuals with sufficient information

10 regarding the advantages and disadvantages of serv11 ice as a commissioned officer in the Regular or Re12 serve Corps of the Public Health Service or a civil13 ian employee of the Service to enable the individual

14 to make a decision on an informed basis.

15 ‘‘(2) CLEAR LANGUAGE.—The application form,

16 contract form, and all other information furnished

17 by the Secretary under this section shall be written

18 in a manner calculated to be understood by the aver19 age individual applying to participate in the Loan

20 Repayment Program.

21 ‘‘(3) TIMELY AVAILABILITY OF FORMS.—The

22 Secretary shall make such application forms, con23 tract forms, and other information available to indi24 viduals desiring to participate in the Loan Repay25 ment Program on a date sufficiently early to ensure
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1 that such individuals have adequate time to carefully

2 review and evaluate such forms and information.

3 ‘‘(d) PRIORITIES.—

4 ‘‘(1) LIST.—Consistent with subsection (k), the

5 Secretary shall annually—

6 ‘‘(A) identify the positions in each Indian

7 Health Program or Urban Indian Organization

8 for which there is a need or a vacancy; and

9 ‘‘(B) rank those positions in order of prior10 ity.

11 ‘‘(2) APPROVALS.—Notwithstanding the prior12 ity determined under paragraph (1), the Secretary,

13 in determining which applications under the Loan

14 Repayment Program to approve (and which con15 tracts to accept), shall—

16 ‘‘(A) give first priority to applications

17 made by individual Indians; and

18 ‘‘(B) after making determinations on all

19 applications submitted by individual Indians as

20 required under subparagraph (A), give priority

21 to—

22 ‘‘(i) individuals recruited through the

23 efforts of an Indian Health Program or

24 Urban Indian Organization; and
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1 ‘‘(ii) other individuals based on the

2 priority rankings under paragraph (1).

3 ‘‘(e) RECIPIENT CONTRACTS.—

4 ‘‘(1) CONTRACT REQUIRED.—An individual be5 comes a participant in the Loan Repayment Pro6 gram only upon the Secretary and the individual en7 tering into a written contract described in paragraph

8 (2).

9 ‘‘(2) CONTENTS OF CONTRACT.—The written

10 contract referred to in this section between the Sec11 retary and an individual shall contain—

12 ‘‘(A) an agreement under which—

13 ‘‘(i) subject to subparagraph (C), the

14 Secretary agrees—

15 ‘‘(I) to pay loans on behalf of the

16 individual in accordance with the pro17 visions of this section; and

18 ‘‘(II) to accept (subject to the

19 availability of appropriated funds for

20 carrying out this section) the individ21 ual into the Service or place the indi22 vidual with a Tribal Health Program

23 or Urban Indian Organization as pro24 vided in clause (ii)(III); and
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1 ‘‘(ii) subject to subparagraph (C), the

2 individual agrees—

3 ‘‘(I) to accept loan payments on

4 behalf of the individual;

5 ‘‘(II) in the case of an individual

6 described in subsection (b)(1)—

7 ‘‘(aa) to maintain enrollment

8 in a course of study or training

9 described in subsection (b)(1)(A)

10 until the individual completes the

11 course of study or training; and

12 ‘‘(bb) while enrolled in such

13 course of study or training, to

14 maintain an acceptable level of

15 academic standing (as deter16 mined under regulations of the

17 Secretary by the educational in18 stitution offering such course of

19 study or training); and

20 ‘‘(III) to serve for a time period

21 (hereinafter in this section referred to

22 as the ‘period of obligated service’)

23 equal to 2 years or such longer period

24 as the individual may agree to serve

25 in the full-time clinical practice of
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•S 1057 IS

1 such individual’s profession in an In2 dian Health Program or Urban In3 dian Organization to which the indi4 vidual may be assigned by the Sec5 retary;

6 ‘‘(B) a provision permitting the Secretary

7 to extend for such longer additional periods, as

8 the individual may agree to, the period of obli9 gated service agreed to by the individual under

10 subparagraph (A)(ii)(III);

11 ‘‘(C) a provision that any financial obliga12 tion of the United States arising out of a con13 tract entered into under this section and any

14 obligation of the individual which is conditioned

15 thereon is contingent upon funds being appro16 priated for loan repayments under this section;

17 ‘‘(D) a statement of the damages to which

18 the United States is entitled under subsection

19 (l) for the individual’s breach of the contract;

20 and

21 ‘‘(E) such other statements of the rights

22 and liabilities of the Secretary and of the indi23 vidual, not inconsistent with this section.
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1 ‘‘(f) DEADLINE FOR DECISION ON APPLICATION.—

2 The Secretary shall provide written notice to an individual

3 within 21 days on—

4 ‘‘(1) the Secretary’s approving, under sub5 section (e)(1), of the individual’s participation in the

6 Loan Repayment Program, including extensions re7 sulting in an aggregate period of obligated service in

8 excess of 4 years; or

9 ‘‘(2) the Secretary’s disapproving an individ10 ual’s participation in such Program.

11 ‘‘(g) PAYMENTS.—

12 ‘‘(1) IN GENERAL.—A loan repayment provided

13 for an individual under a written contract under the

14 Loan Repayment Program shall consist of payment,

15 in accordance with paragraph (2), on behalf of the

16 individual of the principal, interest, and related ex17 penses on government and commercial loans received

18 by the individual regarding the undergraduate or

19 graduate education of the individual (or both), which

20 loans were made for—

21 ‘‘(A) tuition expenses;

22 ‘‘(B) all other reasonable educational ex23 penses, including fees, books, and laboratory ex24 penses, incurred by the individual; and
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•S 1057 IS

1 ‘‘(C) reasonable living expenses as deter2 mined by the Secretary.

3 ‘‘(2) AMOUNT.—For each year of obligated

4 service that an individual contracts to serve under

5 subsection (e), the Secretary may pay up to $35,000

6 or an amount equal to the amount specified in sec7 tion 338B(g)(2)(A) of the Public Health Service

8 Act, whichever is more, on behalf of the individual

9 for loans described in paragraph (1). In making a

10 determination of the amount to pay for a year of

11 such service by an individual, the Secretary shall

12 consider the extent to which each such

13 determination—

14 ‘‘(A) affects the ability of the Secretary to

15 maximize the number of contracts that can be

16 provided under the Loan Repayment Program

17 from the amounts appropriated for such con18 tracts;

19 ‘‘(B) provides an incentive to serve in In20 dian Health Programs and Urban Indian Orga21 nizations with the greatest shortages of health

22 professionals; and

23 ‘‘(C) provides an incentive with respect to

24 the health professional involved remaining in an

25 Indian Health Program or Urban Indian Orga-
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•S 1057 IS

1 nization with such a health professional short2 age, and continuing to provide primary health

3 services, after the completion of the period of

4 obligated service under the Loan Repayment

5 Program.

6 ‘‘(3) TIMING.—Any arrangement made by the

7 Secretary for the making of loan repayments in ac8 cordance with this subsection shall provide that any

9 repayments for a year of obligated service shall be

10 made no later than the end of the fiscal year in

11 which the individual completes such year of service.

12 ‘‘(4) REIMBURSEMENTS FOR TAX LIABILITY.—

13 For the purpose of providing reimbursements for tax

14 liability resulting from a payment under paragraph

15 (2) on behalf of an individual, the Secretary—

16 ‘‘(A) in addition to such payments, may

17 make payments to the individual in an amount

18 equal to not less than 20 percent and not more

19 than 39 percent of the total amount of loan re20 payments made for the taxable year involved;

21 and

22 ‘‘(B) may make such additional payments

23 as the Secretary determines to be appropriate

24 with respect to such purpose.
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1 ‘‘(5) PAYMENT SCHEDULE.—The Secretary

2 may enter into an agreement with the holder of any

3 loan for which payments are made under the Loan

4 Repayment Program to establish a schedule for the

5 making of such payments.

6 ‘‘(h) EMPLOYMENT CEILING.—Notwithstanding any

7 other provision of law, individuals who have entered into

8 written contracts with the Secretary under this section

9 shall not be counted against any employment ceiling af10 fecting the Department while those individuals are under11 going academic training.

12 ‘‘(i) RECRUITMENT.—The Secretary shall conduct re13 cruiting programs for the Loan Repayment Program and

14 other Service manpower programs of the Service at edu15 cational institutions training health professionals or spe16 cialists identified in subsection (a).

17 ‘‘(j) APPLICABILITY OF LAW.—Section 214 of the

18 Public Health Service Act (42 U.S.C. 215) shall not apply

19 to individuals during their period of obligated service

20 under the Loan Repayment Program.

21 ‘‘(k) ASSIGNMENT OF INDIVIDUALS.—The Secretary,

22 in assigning individuals to serve in Indian Health Pro23 grams or Urban Indian Organizations pursuant to con24 tracts entered into under this section, shall—
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•S 1057 IS

1 ‘‘(1) ensure that the staffing needs of Tribal

2 Health Programs and Urban Indian Organizations

3 receive consideration on an equal basis with pro4 grams that are administered directly by the Service;

5 and

6 ‘‘(2) give priority to assigning individuals to In7 dian Health Programs and Urban Indian Organiza8 tions that have a need for health professionals to

9 provide health care services as a result of individuals

10 having breached contracts entered into under this

11 section.

12 ‘‘(l) BREACH OF CONTRACT.—

13 ‘‘(1) SPECIFIC BREACHES.—An individual who

14 has entered into a written contract with the Sec15 retary under this section and has not received a

16 waiver under subsection (m) shall be liable, in lieu

17 of any service obligation arising under such contract,

18 to the United States for the amount which has been

19 paid on such individual’s behalf under the contract

20 if that individual—

21 ‘‘(A) is enrolled in the final year of a

22 course of study and—

23 ‘‘(i) fails to maintain an acceptable

24 level of academic standing in the edu25 cational institution in which he or she is
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1 enrolled (such level determined by the edu2 cational institution under regulations of

3 the Secretary);

4 ‘‘(ii) voluntarily terminates such en5 rollment; or

6 ‘‘(iii) is dismissed from such edu7 cational institution before completion of

8 such course of study; or

9 ‘‘(B) is enrolled in a graduate training pro10 gram and fails to complete such training pro11 gram.

12 ‘‘(2) OTHER BREACHES; FORMULA FOR

13 AMOUNT OWED.—If, for any reason not specified in

14 paragraph (1), an individual breaches his or her

15 written contract under this section by failing either

16 to begin, or complete, such individual’s period of ob17 ligated service in accordance with subsection (e)(2),

18 the United States shall be entitled to recover from

19 such individual an amount to be determined in ac20 cordance with the following formula: A=3Z(t¥s/t)

21 in which—

22 ‘‘(A) ‘A’ is the amount the United States

23 is entitled to recover;

24 ‘‘(B) ‘Z’ is the sum of the amounts paid

25 under this section to, or on behalf of, the indi-
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•S 1057 IS

1 vidual and the interest on such amounts which

2 would be payable if, at the time the amounts

3 were paid, they were loans bearing interest at

4 the maximum legal prevailing rate, as deter5 mined by the Secretary of the Treasury;

6 ‘‘(C) ‘t’ is the total number of months in

7 the individual’s period of obligated service in

8 accordance with subsection (f); and

9 ‘‘(D) ‘s’ is the number of months of such

10 period served by such individual in accordance

11 with this section.

12 ‘‘(3) DEDUCTIONS IN MEDICARE PAYMENTS.—

13 Amounts not paid within such period shall be sub14 ject to collection through deductions in medicare

15 payments pursuant to section 1892 of the Social Se16 curity Act.

17 ‘‘(4) TIME PERIOD FOR REPAYMENT.—Any

18 amount of damages which the United States is enti19 tled to recover under this subsection shall be paid to

20 the United States within the 1-year period beginning

21 on the date of the breach or such longer period be22 ginning on such date as shall be specified by the

23 Secretary.

24 ‘‘(5) RECOVERY OF DELINQUENCY.—
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1 ‘‘(A) IN GENERAL.—If damages described

2 in paragraph (4) are delinquent for 3 months,

3 the Secretary shall, for the purpose of recover4 ing such damages—

5 ‘‘(i) use collection agencies contracted

6 with by the Administrator of General Serv7 ices; or

8 ‘‘(ii) enter into contracts for the re9 covery of such damages with collection

10 agencies selected by the Secretary.

11 ‘‘(B) REPORT.—Each contract for recover12 ing damages pursuant to this subsection shall

13 provide that the contractor will, not less than

14 once each 6 months, submit to the Secretary a

15 status report on the success of the contractor in

16 collecting such damages. Section 3718 of title

17 31, United States Code, shall apply to any such

18 contract to the extent not inconsistent with this

19 subsection.

20 ‘‘(m) WAIVER OR SUSPENSION OF OBLIGATION.—

21 ‘‘(1) IN GENERAL.—The Secretary shall by reg22 ulation provide for the partial or total waiver or sus23 pension of any obligation of service or payment by

24 an individual under the Loan Repayment Program

25 whenever compliance by the individual is impossible
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1 or would involve extreme hardship to the individual

2 and if enforcement of such obligation with respect to

3 any individual would be unconscionable.

4 ‘‘(2) CANCELED UPON DEATH.—Any obligation

5 of an individual under the Loan Repayment Pro6 gram for service or payment of damages shall be

7 canceled upon the death of the individual.

8 ‘‘(3) HARDSHIP WAIVER.—The Secretary may

9 waive, in whole or in part, the rights of the United

10 States to recover amounts under this section in any

11 case of extreme hardship or other good cause shown,

12 as determined by the Secretary.

13 ‘‘(4) BANKRUPTCY.—Any obligation of an indi14 vidual under the Loan Repayment Program for pay15 ment of damages may be released by a discharge in

16 bankruptcy under title 11 of the United States Code

17 only if such discharge is granted after the expiration

18 of the 5-year period beginning on the first date that

19 payment of such damages is required, and only if

20 the bankruptcy court finds that nondischarge of the

21 obligation would be unconscionable.

22 ‘‘(n) REPORT.—The Secretary shall submit to the

23 President, for inclusion in each report required to be sub24 mitted to Congress under section 801, a report concerning
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1 the previous fiscal year which sets forth by Service Area

2 the following:

3 ‘‘(1) A list of the health professional positions

4 maintained by Indian Health Programs and Urban

5 Indian Organizations for which recruitment or reten6 tion is difficult.

7 ‘‘(2) The number of Loan Repayment Program

8 applications filed with respect to each type of health

9 profession.

10 ‘‘(3) The number of contracts described in sub11 section (e) that are entered into with respect to each

12 health profession.

13 ‘‘(4) The amount of loan payments made under

14 this section, in total and by health profession.

15 ‘‘(5) The number of scholarships that are pro16 vided under sections 104 and 106 with respect to

17 each health profession.

18 ‘‘(6) The amount of scholarship grants provided

19 under section 104 and 106, in total and by health

20 profession.

21 ‘‘(7) The number of providers of health care

22 that will be needed by Indian Health Programs and

23 Urban Indian Organizations, by location and profes24 sion, during the 3 fiscal years beginning after the

25 date the report is filed.
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1 ‘‘(8) The measures the Secretary plans to take

2 to fill the health professional positions maintained

3 by Indian Health Programs or Urban Indian Orga4 nizations for which recruitment or retention is dif5 ficult.

6 ‘‘SEC. 111. SCHOLARSHIP AND LOAN REPAYMENT RECOV7 ERY FUND.

8 ‘‘(a) ESTABLISHMENT.—There is established in the

9 Treasury of the United States a fund to be known as the

10 Indian Health Scholarship and Loan Repayment Recovery

11 Fund (hereafter in this section referred to as the ‘LRRF’).

12 The LRRF shall consist of such amounts as may be col13 lected from individuals under section 104(d), section

14 106(e), and section 110(l) for breach of contract, such

15 funds as may be appropriated to the LRRF, and interest

16 earned on amounts in the LRRF. All amounts collected,

17 appropriated, or earned relative to the LRRF shall remain

18 available until expended.

19 ‘‘(b) USE OF FUNDS.—

20 ‘‘(1) BY SECRETARY.—Amounts in the LRRF

21 may be expended by the Secretary, acting through

22 the Service, to make payments to an Indian Health

23 Program—

24 ‘‘(A) to which a scholarship recipient under

25 section 104 and 106 or a loan repayment pro-
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1 gram participant under section 110 has been

2 assigned to meet the obligated service require3 ments pursuant to such sections; and

4 ‘‘(B) that has a need for a health profes5 sional to provide health care services as a result

6 of such recipient or participant having breached

7 the contract entered into under section 104,

8 106, or section 110.

9 ‘‘(2) BY TRIBAL HEALTH PROGRAMS.—A Tribal

10 Health Program receiving payments pursuant to

11 paragraph (1) may expend the payments to provide

12 scholarships or recruit and employ, directly or by

13 contract, health professionals to provide health care

14 services.

15 ‘‘(c) INVESTMENT OF FUNDS.—The Secretary of the

16 Treasury shall invest such amounts of the LRRF as the

17 Secretary of Health and Human Services determines are

18 not required to meet current withdrawals from the LRRF.

19 Such investments may be made only in interest bearing

20 obligations of the United States. For such purpose, such

21 obligations may be acquired on original issue at the issue

22 price, or by purchase of outstanding obligations at the

23 market price.
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1 ‘‘(d) SALE OF OBLIGATIONS.—Any obligation ac2 quired by the LRRF may be sold by the Secretary of the

3 Treasury at the market price.

4 ‘‘SEC. 112. RECRUITMENT ACTIVITIES.

5 ‘‘(a) REIMBURSEMENT FOR TRAVEL.—The Sec6 retary, acting through the Service, may reimburse health

7 professionals seeking positions with Indian Health Pro8 grams or Urban Indian Organizations, including individ9 uals considering entering into a contract under section

10 110 and their spouses, for actual and reasonable expenses

11 incurred in traveling to and from their places of residence

12 to an area in which they may be assigned for the purpose

13 of evaluating such area with respect to such assignment.

14 ‘‘(b) RECRUITMENT PERSONNEL.—The Secretary,

15 acting through the Service, shall assign one individual in

16 each Area Office to be responsible on a full-time basis for

17 recruitment activities.

18 ‘‘SEC. 113. INDIAN RECRUITMENT AND RETENTION PRO19 GRAM.

20 ‘‘(a) IN GENERAL.—The Secretary, acting through

21 the Service, shall fund, on a competitive basis, innovative

22 demonstration projects for a period not to exceed 3 years

23 to enable Tribal Health Programs and Urban Indian Or24 ganizations to recruit, place, and retain health profes25 sionals to meet their staffing needs.
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1 ‘‘(b) ELIGIBLE ENTITIES; APPLICATION.—Any Trib2 al Health Program or Urban Indian Organization may

3 submit an application for funding of a project pursuant

4 to this section.

5 ‘‘SEC. 114. ADVANCED TRAINING AND RESEARCH.

6 ‘‘(a) DEMONSTRATION PROGRAM.—The Secretary,

7 acting through the Service, shall establish a demonstration

8 project to enable health professionals who have worked in

9 an Indian Health Program or Urban Indian Organization

10 for a substantial period of time to pursue advanced train11 ing or research areas of study for which the Secretary de12 termines a need exists.

13 ‘‘(b) SERVICE OBLIGATION.—An individual who par14 ticipates in a program under subsection (a), where the

15 educational costs are borne by the Service, shall incur an

16 obligation to serve in an Indian Health Program or Urban

17 Indian Organization for a period of obligated service equal

18 to at least the period of time during which the individual

19 participates in such program. In the event that the indi20 vidual fails to complete such obligated service, the individ21 ual shall be liable to the United States for the period of

22 service remaining. In such event, with respect to individ23 uals entering the program after the date of enactment of

24 the Indian Health Care Improvement Act Amendments of

25 2005, the United States shall be entitled to recover from
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1 such individual an amount to be determined in accordance

2 with the formula specified in subsection (l) of section 110

3 in the manner provided for in such subsection.

4 ‘‘(c) EQUAL OPPORTUNITY FOR PARTICIPATION.—

5 Health professionals from Tribal Health Programs and

6 Urban Indian Organizations shall be given an equal oppor7 tunity to participate in the program under subsection (a).

8 ‘‘SEC. 115. QUENTIN N. BURDICK AMERICAN INDIANS INTO

9 NURSING PROGRAM.

10 ‘‘(a) GRANTS AUTHORIZED.—For the purpose of in11 creasing the number of nurses, nurse midwives, and nurse

12 practitioners who deliver health care services to Indians,

13 the Secretary, acting through the Service, shall provide

14 grants to the following:

15 ‘‘(1) Public or private schools of nursing.

16 ‘‘(2) Tribal colleges or universities.

17 ‘‘(3) Nurse midwife programs and advanced

18 practice nurse programs that are provided by any

19 tribal college or university accredited nursing pro20 gram, or in the absence of such, any other public or

21 private institutions.

22 ‘‘(b) USE OF GRANTS.—Grants provided under sub23 section (a) may be used for one or more of the following:
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1 ‘‘(1) To recruit individuals for programs which

2 train individuals to be nurses, nurse midwives, or

3 advanced practice nurses.

4 ‘‘(2) To provide scholarships to Indians enrolled

5 in such programs that may pay the tuition charged

6 for such program and other expenses incurred in

7 connection with such program, including books, fees,

8 room and board, and stipends for living expenses.

9 ‘‘(3) To provide a program that encourages

10 nurses, nurse midwives, and advanced practice

11 nurses to provide, or continue to provide, health care

12 services to Indians.

13 ‘‘(4) To provide a program that increases the

14 skills of, and provides continuing education to,

15 nurses, nurse midwives, and advanced practice

16 nurses.

17 ‘‘(5) To provide any program that is designed

18 to achieve the purpose described in subsection (a).

19 ‘‘(c) APPLICATIONS.—Each application for funding

20 under subsection (a) shall include such information as the

21 Secretary may require to establish the connection between

22 the program of the applicant and a health care facility

23 that primarily serves Indians.
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1 ‘‘(d) PREFERENCES FOR GRANT RECIPIENTS.—In

2 providing grants under subsection (a), the Secretary shall

3 extend a preference to the following:

4 ‘‘(1) Programs that provide a preference to In5 dians.

6 ‘‘(2) Programs that train nurse midwives or ad7 vanced practice nurses.

8 ‘‘(3) Programs that are interdisciplinary.

9 ‘‘(4) Programs that are conducted in coopera10 tion with a program for gifted and talented Indian

11 students.

12 ‘‘(e) QUENTIN N. BURDICK PROGRAM GRANT.—The

13 Secretary shall provide one of the grants authorized under

14 subsection (a) to establish and maintain a program at the

15 University of North Dakota to be known as the ‘Quentin

16 N. Burdick American Indians Into Nursing Program’.

17 Such program shall, to the maximum extent feasible, co18 ordinate with the Quentin N. Burdick Indian Health Pro19 grams established under section 117(b) and the Quentin

20 N. Burdick American Indians Into Psychology Program

21 established under section 105(b).

22 ‘‘(f) ACTIVE DUTY SERVICE OBLIGATION.—The ac23 tive duty service obligation prescribed under section 338C

24 of the Public Health Service Act (42 U.S.C. 254m) shall

25 be met by each individual who receives training or assist-
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1 ance described in paragraph (1) or (2) of subsection (b)

2 that is funded by a grant provided under subsection (a).

3 Such obligation shall be met by service—

4 ‘‘(1) in the Service;

5 ‘‘(2) in a program of an Indian Tribe or Tribal

6 Organization conducted under the Indian Self-Deter7 mination and Education Assistance Act (including

8 programs under agreements with the Bureau of In9 dian Affairs);

10 ‘‘(3) in a program assisted under title V of this

11 Act; or

12 ‘‘(4) in the private practice of nursing if, as de13 termined by the Secretary, in accordance with guide14 lines promulgated by the Secretary, such practice is

15 situated in a physician or other health shortage area

16 and addresses the health care needs of a substantial

17 number of Indians.

18 ‘‘SEC. 116. TRIBAL CULTURAL ORIENTATION.

19 ‘‘(a) CULTURAL EDUCATION OF EMPLOYEES.—The

20 Secretary, acting through the Service, shall require that

21 appropriate employees of the Service who serve Indian

22 Tribes in each Service Area receive educational instruction

23 in the history and culture of such Indian Tribes and their

24 relationship to the Service.
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1 ‘‘(b) PROGRAM.—In carrying out subsection (a), the

2 Secretary shall establish a program which shall, to the ex3 tent feasible—

4 ‘‘(1) be developed in consultation with the af5 fected Indian Tribes, Tribal Organizations, and

6 Urban Indian Organizations;

7 ‘‘(2) be carried out through tribal colleges or

8 universities;

9 ‘‘(3) include instruction in American Indian

10 studies; and

11 ‘‘(4) describe the use and place of Traditional

12 Health Care Practices of the Indian Tribes in the

13 Service Area.

14 ‘‘SEC. 117. INMED PROGRAM.

15 ‘‘(a) GRANTS AUTHORIZED.—The Secretary, acting

16 through the Service, is authorized to provide grants to col17 leges and universities for the purpose of maintaining and

18 expanding the Indian health careers recruitment program

19 known as the ‘Indians Into Medicine Program’ (herein20 after in this section referred to as ‘INMED’) as a means

21 of encouraging Indians to enter the health professions.

22 ‘‘(b) QUENTIN N. BURDICK GRANT.—The Secretary

23 shall provide one of the grants authorized under sub24 section (a) to maintain the INMED program at the Uni25 versity of North Dakota, to be known as the ‘Quentin N.
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1 Burdick Indian Health Programs’, unless the Secretary

2 makes a determination, based upon program reviews, that

3 the program is not meeting the purposes of this section.

4 Such program shall, to the maximum extent feasible, co5 ordinate with the Quentin N. Burdick American Indians

6 Into Psychology Program established under section 105(b)

7 and the Quentin N. Burdick American Indians Into Nurs8 ing Program established under section 115.

9 ‘‘(c) REGULATIONS.—The Secretary, pursuant to this

10 Act, shall develop regulations to govern grants pursuant

11 to this section.

12 ‘‘(d) REQUIREMENTS.—Applicants for grants pro13 vided under this section shall agree to provide a program

14 which—

15 ‘‘(1) provides outreach and recruitment for

16 health professions to Indian communities including

17 elementary and secondary schools and community

18 colleges located on reservations which will be served

19 by the program;

20 ‘‘(2) incorporates a program advisory board

21 comprised of representatives from the Indian Tribes

22 and Indian communities which will be served by the

23 program;

24 ‘‘(3) provides summer preparatory programs for

25 Indian students who need enrichment in the subjects
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1 of math and science in order to pursue training in

2 the health professions;

3 ‘‘(4) provides tutoring, counseling, and support

4 to students who are enrolled in a health career pro5 gram of study at the respective college or university;

6 and

7 ‘‘(5) to the maximum extent feasible, employs

8 qualified Indians in the program.

9 ‘‘SEC. 118. HEALTH TRAINING PROGRAMS OF COMMUNITY

10 COLLEGES.

11 ‘‘(a) GRANTS TO ESTABLISH PROGRAMS.—

12 ‘‘(1) IN GENERAL.—The Secretary, acting

13 through the Service, shall award grants to accredited

14 and accessible community colleges for the purpose of

15 assisting such community colleges in the establish16 ment of programs which provide education in a

17 health profession leading to a degree or diploma in

18 a health profession for individuals who desire to

19 practice such profession on or near a reservation or

20 in an Indian Health Program.

21 ‘‘(2) AMOUNT OF GRANTS.—The amount of any

22 grant awarded to a community college under para23 graph (1) for the first year in which such a grant

24 is provided to the community college shall not exceed

25 $100,000.
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1 ‘‘(b) GRANTS FOR MAINTENANCE AND RECRUIT2 ING.—

3 ‘‘(1) IN GENERAL.—The Secretary, acting

4 through the Service, shall award grants to accredited

5 and accessible community colleges that have estab6 lished a program described in subsection (a)(1) for

7 the purpose of maintaining the program and recruit8 ing students for the program.

9 ‘‘(2) REQUIREMENTS.—Grants may only be

10 made under this section to a community college

11 which—

12 ‘‘(A) is accredited;

13 ‘‘(B) has a relationship with a hospital fa14 cility, Service facility, or hospital that could

15 provide training of nurses or health profes16 sionals;

17 ‘‘(C) has entered into an agreement with

18 an accredited college or university medical

19 school, the terms of which—

20 ‘‘(i) provide a program that enhances

21 the transition and recruitment of students

22 into advanced baccalaureate or graduate

23 programs which train health professionals;

24 and
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1 ‘‘(ii) stipulate certifications necessary

2 to approve internship and field placement

3 opportunities at Indian Health Programs;

4 ‘‘(D) has a qualified staff which has the

5 appropriate certifications;

6 ‘‘(E) is capable of obtaining State or re7 gional accreditation of the program described in

8 subsection (a)(1); and

9 ‘‘(F) agrees to provide for Indian pref10 erence for applicants for programs under this

11 section.

12 ‘‘(c) TECHNICAL ASSISTANCE.—The Secretary shall

13 encourage community colleges described in subsection

14 (b)(2) to establish and maintain programs described in

15 subsection (a)(1) by—

16 ‘‘(1) entering into agreements with such col17 leges for the provision of qualified personnel of the

18 Service to teach courses of study in such programs;

19 and

20 ‘‘(2) providing technical assistance and support

21 to such colleges.

22 ‘‘(d) ADVANCED TRAINING.—

23 ‘‘(1) REQUIRED.—Any program receiving as24 sistance under this section that is conducted with re25 spect to a health profession shall also offer courses
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1 of study which provide advanced training for any

2 health professional who—

3 ‘‘(A) has already received a degree or di4 ploma in such health profession; and

5 ‘‘(B) provides clinical services on or near a

6 reservation or for an Indian Health Program.

7 ‘‘(2) MAY BE OFFERED AT ALTERNATE SITE.—

8 Such courses of study may be offered in conjunction

9 with the college or university with which the commu10 nity college has entered into the agreement required

11 under subsection (b)(2)(C).

12 ‘‘(e) FUNDING PRIORITY.—Where the requirements

13 of subsection (b) are met, funding priority shall be pro14 vided to tribal colleges and universities in Service Areas

15 where they exist.

16 ‘‘SEC. 119. RETENTION BONUS.

17 ‘‘(a) BONUS AUTHORIZED.—The Secretary may pay

18 a retention bonus to any health professional employed by,

19 or assigned to, and serving in, an Indian Health Program

20 or Urban Indian Organization either as a civilian employee

21 or as a commissioned officer in the Regular or Reserve

22 Corps of the Public Health Service who—

23 ‘‘(1) is assigned to, and serving in, a position

24 for which recruitment or retention of personnel is

25 difficult;
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1 ‘‘(2) the Secretary determines is needed by In2 dian Health Programs and Urban Indian Organiza3 tions;

4 ‘‘(3) has—

5 ‘‘(A) completed 3 years of employment

6 with an Indian Health Program or Urban In7 dian Organization; or

8 ‘‘(B) completed any service obligations in9 curred as a requirement of—

10 ‘‘(i) any Federal scholarship program;

11 or

12 ‘‘(ii) any Federal education loan re13 payment program; and

14 ‘‘(4) enters into an agreement with an Indian

15 Health Program or Urban Indian Organization for

16 continued employment for a period of not less than

17 1 year.

18 ‘‘(b) RATES.—The Secretary may establish rates for

19 the retention bonus which shall provide for a higher an20 nual rate for multiyear agreements than for single year

21 agreements referred to in subsection (a)(4), but in no

22 event shall the annual rate be more than $25,000 per

23 annum.

24 ‘‘(c) DEFAULT OF RETENTION AGREEMENT.—Any

25 health professional failing to complete the agreed upon
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1 term of service, except where such failure is through no

2 fault of the individual, shall be obligated to refund to the

3 Government the full amount of the retention bonus for the

4 period covered by the agreement, plus interest as deter5 mined by the Secretary in accordance with section

6 110(l)(2)(B).

7 ‘‘(d) OTHER RETENTION BONUS.—The Secretary

8 may pay a retention bonus to any health professional em9 ployed by a Tribal Health Program if such health profes10 sional is serving in a position which the Secretary deter11 mines is—

12 ‘‘(1) a position for which recruitment or reten13 tion is difficult; and

14 ‘‘(2) necessary for providing health care services

15 to Indians.

16 ‘‘SEC. 120. NURSING RESIDENCY PROGRAM.

17 ‘‘(a) ESTABLISHMENT OF PROGRAM.—The Sec18 retary, acting through the Service, shall establish a pro19 gram to enable Indians who are licensed practical nurses,

20 licensed vocational nurses, and registered nurses who are

21 working in an Indian Health Program or Urban Indian

22 Organization, and have done so for a period of not less

23 than 1 year, to pursue advanced training. Such program

24 shall include a combination of education and work study

25 in an Indian Health Program or Urban Indian Organiza-
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1 tion leading to an associate or bachelor’s degree (in the

2 case of a licensed practical nurse or licensed vocational

3 nurse), a bachelor’s degree (in the case of a registered

4 nurse), or advanced degrees or certifications in nursing

5 and public health.

6 ‘‘(b) SERVICE OBLIGATION.—An individual who par7 ticipates in a program under subsection (a), where the

8 educational costs are paid by the Service, shall incur an

9 obligation to serve in an Indian Health Program or Urban

10 Indian Organization for a period of obligated service equal

11 to the amount of time during which the individual partici12 pates in such program. In the event that the individual

13 fails to complete such obligated service, the United States

14 shall be entitled to recover from such individual an amount

15 determined in accordance with the formula specified in

16 subsection (l) of section 110 in the manner provided for

17 in such subsection.

18 ‘‘SEC. 121. COMMUNITY HEALTH AIDE PROGRAM FOR ALAS19 KA.

20 ‘‘(a) GENERAL PURPOSES OF PROGRAM.—Under the

21 authority of the Act of November 2, 1921 (25 U.S.C. 13)

22 (commonly known as the ‘Snyder Act’), the Secretary, act23 ing through the Service, shall develop and operate a Com24 munity Health Aide Program in Alaska under which the

25 Service—
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1 ‘‘(1) provides for the training of Alaska Natives

2 as health aides or community health practitioners;

3 ‘‘(2) uses such aides or practitioners in the pro4 vision of health care, health promotion, and disease

5 prevention services to Alaska Natives living in vil6 lages in rural Alaska; and

7 ‘‘(3) provides for the establishment of tele8 conferencing capacity in health clinics located in or

9 near such villages for use by community health aides

10 or community health practitioners.

11 ‘‘(b) SPECIFIC PROGRAM REQUIREMENTS.—The Sec12 retary, acting through the Community Health Aide Pro13 gram of the Service, shall—

14 ‘‘(1) using trainers accredited by the Program,

15 provide a high standard of training to community

16 health aides and community health practitioners to

17 ensure that such aides and practitioners provide

18 quality health care, health promotion, and disease

19 prevention services to the villages served by the Pro20 gram;

21 ‘‘(2) in order to provide such training, develop

22 a curriculum that—

23 ‘‘(A) combines education in the theory of

24 health care with supervised practical experience

25 in the provision of health care;
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1 ‘‘(B) provides instruction and practical ex2 perience in the provision of acute care, emer3 gency care, health promotion, disease preven4 tion, and the efficient and effective manage5 ment of clinic pharmacies, supplies, equipment,

6 and facilities; and

7 ‘‘(C) promotes the achievement of the

8 health status objectives specified in section

9 3(2);

10 ‘‘(3) establish and maintain a Community

11 Health Aide Certification Board to certify as com12 munity health aides or community health practition13 ers individuals who have successfully completed the

14 training described in paragraph (1) or can dem15 onstrate equivalent experience;

16 ‘‘(4) develop and maintain a system which iden17 tifies the needs of community health aides and com18 munity health practitioners for continuing education

19 in the provision of health care, including the areas

20 described in paragraph (2)(B), and develop pro21 grams that meet the needs for such continuing edu22 cation;

23 ‘‘(5) develop and maintain a system that pro24 vides close supervision of community health aides

25 and community health practitioners; and
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1 ‘‘(6) develop a system under which the work of

2 community health aides and community health prac3 titioners is reviewed and evaluated to assure the pro4 vision of quality health care, health promotion, and

5 disease prevention services.

6 ‘‘(c) NATIONAL COMMUNITY HEALTH AIDE PRO7 GRAM.—

8 ‘‘(1) IN GENERAL.—The Secretary, acting

9 through the Service, is authorized to establish a na10 tional Community Health Aide Program in accord11 ance with subsection (a), except as provided in para12 graphs (2) and (3), without reducing funds for the

13 Community Health Aide Program for Alaska.

14 ‘‘(2) LIMITED CERTIFICATION.—Except for any

15 dental health aide in the State of Alaska, the Sec16 retary, acting through the Community Health Aide

17 Program of the Service, shall ensure that, for a pe18 riod of 4 years, dental health aides are certified only

19 to provide services relating to—

20 ‘‘(A) early childhood dental disease preven21 tion and reversible dental procedures; and

22 ‘‘(B) the development of local capacity to

23 provide those dental services.

24 ‘‘(3) REVIEW.—
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1 ‘‘(A) IN GENERAL.—During the 4-year pe2 riod described in paragraph (2), the Secretary,

3 acting through the Community Health Aide

4 Program of the Service, shall conduct a review

5 of the dental health aide program in the State

6 of Alaska to determine the ability of the pro7 gram to address the dental care needs of Native

8 Alaskans, the quality of care provided (includ9 ing any training, improvement, or additional

10 oversight needed), and whether the program is

11 appropriate and necessary to carry out in any

12 other Indian community.

13 ‘‘(B) REPORT.—After conducting the re14 view under subparagraph (A), the Secretary

15 shall submit to the Committee on Indian Af16 fairs of the Senate and the Committee on Re17 sources of the House of Representatives a re18 port describing any finding of the Secretary

19 under the review.

20 ‘‘(C) FUTURE AUTHORIZATION OF CER21 TIFICATIONS.—Before authorizing any dental

22 procedure not described in paragraph (2)(A),

23 the Secretary shall consult with Indian tribes,

24 Tribal Organizations, Urban Indian Organiza25 tions, and other interested parties to ensure
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1 that the safety and quality of care of the Com2 munity Health Aide Program are adequate and

3 appropriate.

4 ‘‘SEC. 122. TRIBAL HEALTH PROGRAM ADMINISTRATION.

5 ‘‘The Secretary, acting through the Service, shall, by

6 contract or otherwise, provide training for Indians in the

7 administration and planning of Tribal Health Programs.

8 ‘‘SEC. 123. HEALTH PROFESSIONAL CHRONIC SHORTAGE

9 DEMONSTRATION PROGRAMS.

10 ‘‘(a) DEMONSTRATION PROGRAMS AUTHORIZED.—

11 The Secretary, acting through the Service, may fund dem12 onstration programs for Tribal Health Programs to ad13 dress the chronic shortages of health professionals.

14 ‘‘(b) PURPOSES OF PROGRAMS.—The purposes of

15 demonstration programs funded under subsection (a) shall

16 be—

17 ‘‘(1) to provide direct clinical and practical ex18 perience at a Service Unit to health profession stu19 dents and residents from medical schools;

20 ‘‘(2) to improve the quality of health care for

21 Indians by assuring access to qualified health care

22 professionals; and

23 ‘‘(3) to provide academic and scholarly opportu24 nities for health professionals serving Indians by
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1 identifying all academic and scholarly resources of

2 the region.

3 ‘‘(c) ADVISORY BOARD.—The demonstration pro4 grams established pursuant to subsection (a) shall incor5 porate a program advisory board composed of representa6 tives from the Indian Tribes and Indian communities in

7 the area which will be served by the program.

8 ‘‘SEC. 124. NATIONAL HEALTH SERVICE CORPS.

9 ‘‘(a) NO REDUCTION IN SERVICES.—The Secretary

10 shall not—

11 ‘‘(1) remove a member of the National Health

12 Service Corps from an Indian Health Program or

13 Urban Indian Organization; or

14 ‘‘(2) withdraw funding used to support such

15 member, unless the Secretary, acting through the

16 Service, Indian Tribes, or Tribal Organizations, has

17 ensured that the Indians receiving services from

18 such member will experience no reduction in serv19 ices.

20 ‘‘(b) EXEMPTION FROM LIMITATIONS.—National

21 Health Service Corps scholars qualifying for the Commis22 sioned Corps in the United States Public Health Service

23 shall be exempt from the full-time equivalent limitations

24 of the National Health Service Corps and the Service
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1 when serving as a commissioned corps officer in a Tribal

2 Health Program or an Urban Indian Organization.

3 ‘‘SEC. 125. SUBSTANCE ABUSE COUNSELOR EDUCATIONAL

4 CURRICULA DEMONSTRATION PROGRAMS.

5 ‘‘(a) GRANTS AND CONTRACTS.—The Secretary, act6 ing through the Service, may enter into contracts with,

7 or make grants to, accredited tribal colleges and univer8 sities and eligible accredited and accessible community col9 leges to establish demonstration programs to develop edu10 cational curricula for substance abuse counseling.

11 ‘‘(b) USE OF FUNDS.—Funds provided under this

12 section shall be used only for developing and providing

13 educational curriculum for substance abuse counseling (in14 cluding paying salaries for instructors). Such curricula

15 may be provided through satellite campus programs.

16 ‘‘(c) TIME PERIOD OF ASSISTANCE; RENEWAL.—A

17 contract entered into or a grant provided under this sec18 tion shall be for a period of 1 year. Such contract or grant

19 may be renewed for an additional 1-year period upon the

20 approval of the Secretary.

21 ‘‘(d) CRITERIA FOR REVIEW AND APPROVAL OF AP22 PLICATIONS.—Not later than 180 days after the date of

23 enactment of the Indian Health Care Improvement Act

24 Amendments of 2005, the Secretary, after consultation

25 with Indian Tribes and administrators of tribal colleges
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1 and universities and eligible accredited and accessible com2 munity colleges, shall develop and issue criteria for the

3 review and approval of applications for funding (including

4 applications for renewals of funding) under this section.

5 Such criteria shall ensure that demonstration programs

6 established under this section promote the development of

7 the capacity of such entities to educate substance abuse

8 counselors.

9 ‘‘(e) ASSISTANCE.—The Secretary shall provide such

10 technical and other assistance as may be necessary to en11 able grant recipients to comply with the provisions of this

12 section.

13 ‘‘(f) REPORT.—Each fiscal year, the Secretary shall

14 submit to the President, for inclusion in the report which

15 is required to be submitted under section 801 for that fis16 cal year, a report on the findings and conclusions derived

17 from the demonstration programs conducted under this

18 section during that fiscal year.

19 ‘‘(g) DEFINITION.—For the purposes of this section,

20 the term ‘educational curriculum’ means 1 or more of the

21 following:

22 ‘‘(1) Classroom education.

23 ‘‘(2) Clinical work experience.

24 ‘‘(3) Continuing education workshops.
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1 ‘‘SEC. 126. BEHAVIORAL HEALTH TRAINING AND COMMU2 NITY EDUCATION PROGRAMS.

3 ‘‘(a) STUDY; LIST.—The Secretary, acting through

4 the Service, and the Secretary of the Interior, in consulta5 tion with Indian Tribes and Tribal Organizations, shall

6 conduct a study and compile a list of the types of staff

7 positions specified in subsection (b) whose qualifications

8 include, or should include, training in the identification,

9 prevention, education, referral, or treatment of mental ill10 ness, or dysfunctional and self destructive behavior.

11 ‘‘(b) POSITIONS.—The positions referred to in sub12 section (a) are—

13 ‘‘(1) staff positions within the Bureau of Indian

14 Affairs, including existing positions, in the fields

15 of—

16 ‘‘(A) elementary and secondary education;

17 ‘‘(B) social services and family and child

18 welfare;

19 ‘‘(C) law enforcement and judicial services;

20 and

21 ‘‘(D) alcohol and substance abuse;

22 ‘‘(2) staff positions within the Service; and

23 ‘‘(3) staff positions similar to those identified in

24 paragraphs (1) and (2) established and maintained

25 by Indian Tribes, Tribal Organizations (without re-
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1 gard to the funding source), and Urban Indian Or2 ganizations.

3 ‘‘(c) TRAINING CRITERIA.—

4 ‘‘(1) IN GENERAL.—The appropriate Secretary

5 shall provide training criteria appropriate to each

6 type of position identified in subsection (b)(1) and

7 (b)(2) and ensure that appropriate training has

8 been, or shall be provided to any individual in any

9 such position. With respect to any such individual in

10 a position identified pursuant to subsection (b)(3),

11 the respective Secretaries shall provide appropriate

12 training to, or provide funds to, an Indian Tribe,

13 Tribal Organization, or Urban Indian Organization

14 for training of appropriate individuals. In the case of

15 positions funded under a contract or compact under

16 the Indian Self-Determination and Education Assist17 ance Act (25 U.S.C. 450 et seq.), the appropriate

18 Secretary shall ensure that such training costs are

19 included in the contract or compact, as the Sec20 retary determines necessary.

21 ‘‘(2) POSITION SPECIFIC TRAINING CRITERIA.—

22 Position specific training criteria shall be culturally

23 relevant to Indians and Indian Tribes and shall en24 sure that appropriate information regarding Tradi25 tional Health Care Practices is provided.
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1 ‘‘(d) COMMUNITY EDUCATION ON MENTAL ILL2 NESS.—The Service shall develop and implement, on re3 quest of an Indian Tribe, Tribal Organization, or Urban

4 Indian Organization, or assist the Indian Tribe, Tribal Or5 ganization, or Urban Indian Organization to develop and

6 implement, a program of community education on mental

7 illness. In carrying out this subsection, the Service shall,

8 upon request of an Indian Tribe, Tribal Organization, or

9 Urban Indian Organization, provide technical assistance

10 to the Indian Tribe, Tribal Organization, or Urban Indian

11 Organization to obtain and develop community edu12 cational materials on the identification, prevention, refer13 ral, and treatment of mental illness and dysfunctional and

14 self-destructive behavior.

15 ‘‘(e) PLAN.—Not later than 90 days after the date

16 of enactment of the Indian Health Care Improvement Act

17 Amendments of 2005, the Secretary shall develop a plan

18 under which the Service will increase the health care staff

19 providing behavioral health services by at least 500 posi20 tions within 5 years after the date of enactment of this

21 section, with at least 200 of such positions devoted to

22 child, adolescent, and family services. The plan developed

23 under this subsection shall be implemented under the Act

24 of November 2, 1921 (25 U.S.C. 13) (commonly known

25 as the ‘Snyder Act’).
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1 ‘‘SEC. 127. AUTHORIZATION OF APPROPRIATIONS.

2 ‘‘There are authorized to be appropriated such sums

3 as may be necessary for each fiscal year through fiscal

4 year 2015 to carry out this title.

5 ‘‘TITLE II—HEALTH SERVICES

6 ‘‘SEC. 201. INDIAN HEALTH CARE IMPROVEMENT FUND.

7 ‘‘(a) USE OF FUNDS.—The Secretary, acting through

8 the Service, is authorized to expend funds, directly or

9 under the authority of the Indian Self-Determination and

10 Education Assistance Act (25 U.S.C. 450 et seq.), which

11 are appropriated under the authority of this section, for

12 the purposes of—

13 ‘‘(1) eliminating the deficiencies in health sta14 tus and health resources of all Indian Tribes;

15 ‘‘(2) eliminating backlogs in the provision of

16 health care services to Indians;

17 ‘‘(3) meeting the health needs of Indians in an

18 efficient and equitable manner, including the use of

19 telehealth and telemedicine when appropriate;

20 ‘‘(4) eliminating inequities in funding for both

21 direct care and contract health service programs;

22 and

23 ‘‘(5) augmenting the ability of the Service to

24 meet the following health service responsibilities with

25 respect to those Indian Tribes with the highest levels
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1 of health status deficiencies and resource defi2 ciencies:

3 ‘‘(A) Clinical care, including inpatient care,

4 outpatient care (including audiology, clinical

5 eye, and vision care), primary care, secondary

6 and tertiary care, and long-term care.

7 ‘‘(B) Preventive health, including mam8 mography and other cancer screening in accord9 ance with section 207.

10 ‘‘(C) Dental care.

11 ‘‘(D) Mental health, including community

12 mental health services, inpatient mental health

13 services, dormitory mental health services,

14 therapeutic and residential treatment centers,

15 and training of traditional health care practi16 tioners.

17 ‘‘(E) Emergency medical services.

18 ‘‘(F) Treatment and control of, and reha19 bilitative care related to, alcoholism and drug

20 abuse (including fetal alcohol syndrome) among

21 Indians.

22 ‘‘(G) Accident prevention programs.

23 ‘‘(H) Home health care.

24 ‘‘(I) Community health representatives.

25 ‘‘(J) Maintenance and repair.
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1 ‘‘(K) Traditional Health Care Practices.

2 ‘‘(b) NO OFFSET OR LIMITATION.—Any funds appro3 priated under the authority of this section shall not be

4 used to offset or limit any other appropriations made to

5 the Service under this Act or the Act of November 2, 1921

6 (25 U.S.C. 13) (commonly known as the ‘Snyder Act’),

7 or any other provision of law.

8 ‘‘(c) ALLOCATION; USE.—

9 ‘‘(1) IN GENERAL.—Funds appropriated under

10 the authority of this section shall be allocated to

11 Service Units, Indian Tribes, or Tribal Organiza12 tions. The funds allocated to each Indian Tribe,

13 Tribal Organization, or Service Unit under this

14 paragraph shall be used by the Indian Tribe, Tribal

15 Organization, or Service Unit under this paragraph

16 to improve the health status and reduce the resource

17 deficiency of each Indian Tribe served by such Serv18 ice Unit, Indian Tribe, or Tribal Organization.

19 ‘‘(2) APPORTIONMENT OF ALLOCATED

20 FUNDS.—The apportionment of funds allocated to a

21 Service Unit, Indian Tribe, or Tribal Organization

22 under paragraph (1) among the health service re23 sponsibilities described in subsection (a)(5) shall be

24 determined by the Service in consultation with, and
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1 with the active participation of, the affected Indian

2 Tribes and Tribal Organizations.

3 ‘‘(d) PROVISIONS RELATING TO HEALTH STATUS

4 AND RESOURCE DEFICIENCIES.—For the purposes of this

5 section, the following definitions apply:

6 ‘‘(1) DEFINITION.—The term ‘health status

7 and resource deficiency’ means the extent to

8 which—

9 ‘‘(A) the health status objectives set forth

10 in section 3(2) are not being achieved; and

11 ‘‘(B) the Indian Tribe or Tribal Organiza12 tion does not have available to it the health re13 sources it needs, taking into account the actual

14 cost of providing health care services given local

15 geographic, climatic, rural, or other cir16 cumstances.

17 ‘‘(2) AVAILABLE RESOURCES.—The health re18 sources available to an Indian Tribe or Tribal Orga19 nization include health resources provided by the

20 Service as well as health resources used by the In21 dian Tribe or Tribal Organization, including services

22 and financing systems provided by any Federal pro23 grams, private insurance, and programs of State or

24 local governments.
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1 ‘‘(3) PROCESS FOR REVIEW OF DETERMINA2 TIONS.—The Secretary shall establish procedures

3 which allow any Indian Tribe or Tribal Organization

4 to petition the Secretary for a review of any deter5 mination of the extent of the health status and re6 source deficiency of such Indian Tribe or Tribal Or7 ganization.

8 ‘‘(e) ELIGIBILITY FOR FUNDS.—Tribal Health Pro9 grams shall be eligible for funds appropriated under the

10 authority of this section on an equal basis with programs

11 that are administered directly by the Service.

12 ‘‘(f) REPORT.—By no later than the date that is 3

13 years after the date of enactment of the Indian Health

14 Care Improvement Act Amendments of 2005, the Sec15 retary shall submit to Congress the current health status

16 and resource deficiency report of the Service for each

17 Service Unit, including newly recognized or acknowledged

18 Indian Tribes. Such report shall set out—

19 ‘‘(1) the methodology then in use by the Service

20 for determining Tribal health status and resource

21 deficiencies, as well as the most recent application of

22 that methodology;

23 ‘‘(2) the extent of the health status and re24 source deficiency of each Indian Tribe served by the

25 Service or a Tribal Health Program;
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1 ‘‘(3) the amount of funds necessary to eliminate

2 the health status and resource deficiencies of all In3 dian Tribes served by the Service or a Tribal Health

4 Program; and

5 ‘‘(4) an estimate of—

6 ‘‘(A) the amount of health service funds

7 appropriated under the authority of this Act, or

8 any other Act, including the amount of any

9 funds transferred to the Service for the preced10 ing fiscal year which is allocated to each Service

11 Unit, Indian Tribe, or Tribal Organization;

12 ‘‘(B) the number of Indians eligible for

13 health services in each Service Unit or Indian

14 Tribe or Tribal Organization; and

15 ‘‘(C) the number of Indians using the

16 Service resources made available to each Service

17 Unit, Indian Tribe or Tribal Organization, and,

18 to the extent available, information on the wait19 ing lists and number of Indians turned away for

20 services due to lack of resources.

21 ‘‘(g) INCLUSION IN BASE BUDGET.—Funds appro22 priated under this section for any fiscal year shall be in23 cluded in the base budget of the Service for the purpose

24 of determining appropriations under this section in subse25 quent fiscal years.
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1 ‘‘(h) CLARIFICATION.—Nothing in this section is in2 tended to diminish the primary responsibility of the Serv3 ice to eliminate existing backlogs in unmet health care

4 needs, nor are the provisions of this section intended to

5 discourage the Service from undertaking additional efforts

6 to achieve equity among Indian Tribes and Tribal Organi7 zations.

8 ‘‘(i) FUNDING DESIGNATION.—Any funds appro9 priated under the authority of this section shall be des10 ignated as the ‘Indian Health Care Improvement Fund’.

11 ‘‘SEC. 202. CATASTROPHIC HEALTH EMERGENCY FUND.

12 ‘‘(a) ESTABLISHMENT.—There is established an In13 dian Catastrophic Health Emergency Fund (hereafter in

14 this section referred to as the ‘CHEF’) consisting of—

15 ‘‘(1) the amounts deposited under subsection

16 (f); and

17 ‘‘(2) the amounts appropriated to CHEF under

18 this section.

19 ‘‘(b) ADMINISTRATION.—CHEF shall be adminis20 tered by the Secretary, acting through the central office

21 of the Service, solely for the purpose of meeting the ex22 traordinary medical costs associated with the treatment of

23 victims of disasters or catastrophic illnesses who are with24 in the responsibility of the Service.
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1 ‘‘(c) CONDITIONS ON USE OF FUND.—No part of

2 CHEF or its administration shall be subject to contract

3 or grant under any law, including the Indian Self-Deter4 mination and Education Assistance Act (25 U.S.C. 450

5 et seq.), nor shall CHEF funds be allocated, apportioned,

6 or delegated on an Area Office, Service Unit, or other

7 similar basis.

8 ‘‘(d) REGULATIONS.—The Secretary shall, through

9 the negotiated rulemaking process under title VIII, pro10 mulgate regulations consistent with the provisions of this

11 section to—

12 ‘‘(1) establish a definition of disasters and cata13 strophic illnesses for which the cost of the treatment

14 provided under contract would qualify for payment

15 from CHEF;

16 ‘‘(2) provide that a Service Unit shall not be el17 igible for reimbursement for the cost of treatment

18 from CHEF until its cost of treating any victim of

19 such catastrophic illness or disaster has reached a

20 certain threshold cost which the Secretary shall es21 tablish at—

22 ‘‘(A) the 2000 level of $19,000; and

23 ‘‘(B) for any subsequent year, not less

24 than the threshold cost of the previous year in25 creased by the percentage increase in the medi-
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1 cal care expenditure category of the consumer

2 price index for all urban consumers (United

3 States city average) for the 12-month period

4 ending with December of the previous year;

5 ‘‘(3) establish a procedure for the reimburse6 ment of the portion of the costs that exceeds such

7 threshold cost incurred by—

8 ‘‘(A) Service Units; or

9 ‘‘(B) whenever otherwise authorized by the

10 Service, non-Service facilities or providers;

11 ‘‘(4) establish a procedure for payment from

12 CHEF in cases in which the exigencies of the medi13 cal circumstances warrant treatment prior to the au14 thorization of such treatment by the Service; and

15 ‘‘(5) establish a procedure that will ensure that

16 no payment shall be made from CHEF to any pro17 vider of treatment to the extent that such provider

18 is eligible to receive payment for the treatment from

19 any other Federal, State, local, or private source of

20 reimbursement for which the patient is eligible.

21 ‘‘(e) NO OFFSET OR LIMITATION.—Amounts appro22 priated to CHEF under this section shall not be used to

23 offset or limit appropriations made to the Service under

24 the authority of the Act of November 2, 1921 (25 U.S.C.
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1 13) (commonly known as the ‘Snyder Act’), or any other

2 law.

3 ‘‘(f) DEPOSIT OF REIMBURSEMENT FUNDS.—There

4 shall be deposited into CHEF all reimbursements to which

5 the Service is entitled from any Federal, State, local, or

6 private source (including third party insurance) by reason

7 of treatment rendered to any victim of a disaster or cata8 strophic illness the cost of which was paid from CHEF.

9 ‘‘SEC. 203. HEALTH PROMOTION AND DISEASE PREVENTION

10 SERVICES.

11 ‘‘(a) FINDINGS.—Congress finds that health pro12 motion and disease prevention activities—

13 ‘‘(1) improve the health and well-being of Indi14 ans; and

15 ‘‘(2) reduce the expenses for health care of In16 dians.

17 ‘‘(b) PROVISION OF SERVICES.—The Secretary, act18 ing through the Service and Tribal Health Programs, shall

19 provide health promotion and disease prevention services

20 to Indians to achieve the health status objectives set forth

21 in section 3(2).

22 ‘‘(c) EVALUATION.—The Secretary, after obtaining

23 input from the affected Tribal Health Programs, shall

24 submit to the President for inclusion in each report which
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1 is required to be submitted to Congress under section 801

2 an evaluation of—

3 ‘‘(1) the health promotion and disease preven4 tion needs of Indians;

5 ‘‘(2) the health promotion and disease preven6 tion activities which would best meet such needs;

7 ‘‘(3) the internal capacity of the Service and

8 Tribal Health Programs to meet such needs; and

9 ‘‘(4) the resources which would be required to

10 enable the Service and Tribal Health Programs to

11 undertake the health promotion and disease preven12 tion activities necessary to meet such needs.

13 ‘‘SEC. 204. DIABETES PREVENTION, TREATMENT, AND CON14 TROL.

15 ‘‘(a) DETERMINATIONS REGARDING DIABETES.—

16 The Secretary, acting through the Service, and in con17 sultation with Indian Tribes and Tribal Organizations,

18 shall determine—

19 ‘‘(1) by Indian Tribe and by Service Unit, the

20 incidence of, and the types of complications resulting

21 from, diabetes among Indians; and

22 ‘‘(2) based on the determinations made pursu23 ant to paragraph (1), the measures (including pa24 tient education and effective ongoing monitoring of

25 disease indicators) each Service Unit should take to
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1 reduce the incidence of, and prevent, treat, and con2 trol the complications resulting from, diabetes

3 among Indian Tribes within that Service Unit.

4 ‘‘(b) DIABETES SCREENING.—To the extent medi5 cally indicated and with informed consent, the Secretary

6 shall screen each Indian who receives services from the

7 Service for diabetes and for conditions which indicate a

8 high risk that the individual will become diabetic and, in

9 consultation with Indian Tribes, Urban Indian Organiza10 tions, and appropriate health care providers, establish a

11 cost-effective approach to ensure ongoing monitoring of

12 disease indicators. Such screening and monitoring may be

13 conducted by a Tribal Health Program and may be con14 ducted through appropriate Internet-based health care

15 management programs.

16 ‘‘(c) FUNDING FOR DIABETES.—The Secretary shall

17 continue to maintain each model diabetes project in exist18 ence on the date of enactment of the Indian Health

19 Amendments Care Improvement Act of 2005, any such

20 other diabetes programs operated by the Service or Tribal

21 Health Programs, and any additional diabetes projects,

22 such as the Medical Vanguard program provided for in

23 title IV of Public Law 108–87, as implemented to serve

24 Indian Tribes. Tribal Health Programs shall receive recur25 ring funding for the diabetes projects that they operate
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1 pursuant to this section, both at the date of enactment

2 of the Indian Health Care Improvement Act Amendments

3 of 2005 and for projects which are added and funded

4 thereafter.

5 ‘‘(d) FUNDING FOR DIALYSIS PROGRAMS.—The Sec6 retary is authorized to provide funding through the Serv7 ice, Indian Tribes, and Tribal Organizations to establish

8 dialysis programs, including funding to purchase dialysis

9 equipment and provide necessary staffing.

10 ‘‘(e) OTHER DUTIES OF THE SECRETARY.—The Sec11 retary shall, to the extent funding is available—

12 ‘‘(1) in each Area Office, consult with Indian

13 Tribes and Tribal Organizations regarding programs

14 for the prevention, treatment, and control of diabe15 tes;

16 ‘‘(2) establish in each Area Office a registry of

17 patients with diabetes to track the incidence of dia18 betes and the complications from diabetes in that

19 area; and

20 ‘‘(3) ensure that data collected in each Area Of21 fice regarding diabetes and related complications

22 among Indians are disseminated to all other Area

23 Offices, subject to applicable patient privacy laws.
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1 ‘‘SEC. 205. SHARED SERVICES FOR LONG-TERM CARE.

2 ‘‘(a) LONG-TERM CARE.—Notwithstanding any other

3 provision of law, the Secretary, acting through the Service,

4 is authorized to provide directly, or enter into contracts

5 or compacts under the Indian Self-Determination and

6 Education Assistance Act (25 U.S.C. 450 et seq.) with

7 Indian Tribes or Tribal Organizations for, the delivery of

8 long-term care and similar services to Indians. Such agree9 ments shall provide for the sharing of staff or other serv10 ices between the Service or a Tribal Health Program and

11 a long-term care or other similar facility owned and oper12 ated (directly or through a contract or compact under the

13 Indian Self-Determination and Education Assistance Act

14 (25 U.S.C. 450 et seq.)) by such Indian Tribe or Tribal

15 Organization.

16 ‘‘(b) CONTENTS OF AGREEMENTS.—An agreement

17 entered into pursuant to subsection (a)—

18 ‘‘(1) may, at the request of the Indian Tribe or

19 Tribal Organization, delegate to such Indian Tribe

20 or Tribal Organization such powers of supervision

21 and control over Service employees as the Secretary

22 deems necessary to carry out the purposes of this

23 section;

24 ‘‘(2) shall provide that expenses (including sala25 ries) relating to services that are shared between the

26 Service and the Tribal Health Program be allocated
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1 proportionately between the Service and the Indian

2 Tribe or Tribal Organization; and

3 ‘‘(3) may authorize such Indian Tribe or Tribal

4 Organization to construct, renovate, or expand a

5 long-term care or other similar facility (including the

6 construction of a facility attached to a Service facil7 ity).

8 ‘‘(c) MINIMUM REQUIREMENT.—Any nursing facility

9 provided for under this section shall meet the require10 ments for nursing facilities under section 1919 of the So11 cial Security Act.

12 ‘‘(d) OTHER ASSISTANCE.—The Secretary shall pro13 vide such technical and other assistance as may be nec14 essary to enable applicants to comply with the provisions

15 of this section.

16 ‘‘(e) USE OF EXISTING OR UNDERUSED FACILI17 TIES.—The Secretary shall encourage the use of existing

18 facilities that are underused or allow the use of swing beds

19 for long-term or similar care.

20 ‘‘SEC. 206. HEALTH SERVICES RESEARCH.

21 ‘‘The Secretary, acting through the Service, shall

22 make funding available for research to further the per23 formance of the health service responsibilities of Indian

24 Health Programs. The Secretary shall also, to the maxi25 mum extent practicable, coordinate departmental research
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1 resources and activities to address relevant Indian Health

2 Program research needs. Tribal Health Programs shall be

3 given an equal opportunity to compete for, and receive,

4 research funds under this section. This funding may be

5 used for both clinical and nonclinical research.

6 ‘‘SEC. 207. MAMMOGRAPHY AND OTHER CANCER SCREEN7 ING.

8 ‘‘The Secretary, acting through the Service or Tribal

9 Health Programs, shall provide for screening as follows:

10 ‘‘(1) Screening mammography (as defined in

11 section 1861(jj) of the Social Security Act) for In12 dian women at a frequency appropriate to such

13 women under accepted and appropriate national

14 standards, and under such terms and conditions as

15 are consistent with standards established by the Sec16 retary to ensure the safety and accuracy of screen17 ing mammography under part B of title XVIII of

18 such Act.

19 ‘‘(2) Other cancer screening meeting accepted

20 and appropriate national standards.

21 ‘‘SEC. 208. PATIENT TRAVEL COSTS.

22 ‘‘The Secretary, acting through the Service and Trib23 al Health Programs, is authorized to provide funds for the

24 following patient travel costs, including appropriate and

25 necessary qualified escorts, associated with receiving
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1 health care services provided (either through direct or con2 tract care or through a contract or compact under the In3 dian Self-Determination and Education Assistance Act

4 (25 U.S.C. 450 et seq.)) under this Act—

5 ‘‘(1) emergency air transportation and non6 emergency air transportation where ground trans7 portation is infeasible;

8 ‘‘(2) transportation by private vehicle (where no

9 other means of transportation is available), specially

10 equipped vehicle, and ambulance; and

11 ‘‘(3) transportation by such other means as

12 may be available and required when air or motor ve13 hicle transportation is not available.

14 ‘‘SEC. 209. EPIDEMIOLOGY CENTERS.

15 ‘‘(a) ADDITIONAL CENTERS.—In addition to those

16 epidemiology centers already established as of the date of

17 enactment of this Act, and without reducing the funding

18 levels for such centers, not later than 180 days after the

19 date of enactment of the Indian Health Care Improvement

20 Act Amendments of 2005, the Secretary, acting through

21 the Service, shall establish and fund an epidemiology cen22 ter in each Service Area which does not yet have one to

23 carry out the functions described in subsection (b). Any

24 new centers so established may be operated by Tribal

25 Health Programs, but such funding shall not be divisible.
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1 ‘‘(b) FUNCTIONS OF CENTERS.—In consultation with

2 and upon the request of Indian Tribes, Tribal Organiza3 tions, and Urban Indian Organizations, each Service Area

4 epidemiology center established under this subsection

5 shall, with respect to such Service Area—

6 ‘‘(1) collect data relating to, and monitor

7 progress made toward meeting, each of the health

8 status objectives of the Service, the Indian Tribes,

9 Tribal Organizations, and Urban Indian Organiza10 tions in the Service Area;

11 ‘‘(2) evaluate existing delivery systems, data

12 systems, and other systems that impact the improve13 ment of Indian health;

14 ‘‘(3) assist Indian Tribes, Tribal Organizations,

15 and Urban Indian Organizations in identifying their

16 highest priority health status objectives and the

17 services needed to achieve such objectives, based on

18 epidemiological data;

19 ‘‘(4) make recommendations for the targeting

20 of services needed by the populations served;

21 ‘‘(5) make recommendations to improve health

22 care delivery systems for Indians and Urban Indi23 ans;

24 ‘‘(6) provide requested technical assistance to

25 Indian Tribes, Tribal Organizations, and Urban In-
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1 dian Organizations in the development of local

2 health service priorities and incidence and prevalence

3 rates of disease and other illness in the community;

4 and

5 ‘‘(7) provide disease surveillance and assist In6 dian Tribes, Tribal Organizations, and Urban Indian

7 Organizations to promote public health.

8 ‘‘(c) TECHNICAL ASSISTANCE.—The Director of the

9 Centers for Disease Control and Prevention shall provide

10 technical assistance to the centers in carrying out the re11 quirements of this subsection.

12 ‘‘(d) FUNDING FOR STUDIES.—The Secretary may

13 make funding available to Indian Tribes, Tribal Organiza14 tions, and Urban Indian Organizations to conduct epide15 miological studies of Indian communities.

16 ‘‘SEC. 210. COMPREHENSIVE SCHOOL HEALTH EDUCATION

17 PROGRAMS.

18 ‘‘(a) FUNDING FOR DEVELOPMENT OF PROGRAMS.—

19 In addition to carrying out any other program for health

20 promotion or disease prevention, the Secretary, acting

21 through the Service, is authorized to award grants to In22 dian Tribes, Tribal Organizations, and Urban Indian Or23 ganizations to develop comprehensive school health edu24 cation programs for children from pre-school through
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1 grade 12 in schools for the benefit of Indian and Urban

2 Indian children.

3 ‘‘(b) USE OF FUNDS.—Funding provided under this

4 section may be used for purposes which may include, but

5 are not limited to, the following:

6 ‘‘(1) Developing and implementing health edu7 cation curricula both for regular school programs

8 and afterschool programs.

9 ‘‘(2) Training teachers in comprehensive school

10 health education curricula.

11 ‘‘(3) Integrating school-based, community12 based, and other public and private health promotion

13 efforts.

14 ‘‘(4) Encouraging healthy, tobacco-free school

15 environments.

16 ‘‘(5) Coordinating school-based health programs

17 with existing services and programs available in the

18 community.

19 ‘‘(6) Developing school programs on nutrition

20 education, personal health, oral health, and fitness.

21 ‘‘(7) Developing behavioral health wellness pro22 grams.

23 ‘‘(8) Developing chronic disease prevention pro24 grams.
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1 ‘‘(9) Developing substance abuse prevention

2 programs.

3 ‘‘(10) Developing injury prevention and safety

4 education programs.

5 ‘‘(11) Developing activities for the prevention

6 and control of communicable diseases.

7 ‘‘(12) Developing community and environmental

8 health education programs that include traditional

9 health care practitioners.

10 ‘‘(13) Violence prevention.

11 ‘‘(14) Such other health issues as are appro12 priate.

13 ‘‘(c) TECHNICAL ASSISTANCE.—Upon request, the

14 Secretary, acting through the Service, shall provide tech15 nical assistance to Indian Tribes, Tribal Organizations,

16 and Urban Indian Organizations in the development of

17 comprehensive health education plans and the dissemina18 tion of comprehensive health education materials and in19 formation on existing health programs and resources.

20 ‘‘(d) CRITERIA FOR REVIEW AND APPROVAL OF AP21 PLICATIONS.—The Secretary, acting through the Service,

22 and in consultation with Indian Tribes, Tribal Organiza23 tions, and Urban Indian Organizations, shall establish cri24 teria for the review and approval of applications for fund25 ing provided pursuant to this section.
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1 ‘‘(e) DEVELOPMENT OF PROGRAM FOR BIA FUNDED

2 SCHOOLS.—

3 ‘‘(1) IN GENERAL.—The Secretary of the Inte4 rior, acting through the Bureau of Indian Affairs

5 and in cooperation with the Secretary, acting

6 through the Service, and affected Indian Tribes and

7 Tribal Organizations, shall develop a comprehensive

8 school health education program for children from

9 preschool through grade 12 in schools for which sup10 port is provided by the Bureau of Indian Affairs.

11 ‘‘(2) REQUIREMENTS FOR PROGRAMS.—Such

12 programs shall include—

13 ‘‘(A) school programs on nutrition edu14 cation, personal health, oral health, and fitness;

15 ‘‘(B) behavioral health wellness programs;

16 ‘‘(C) chronic disease prevention programs;

17 ‘‘(D) substance abuse prevention pro18 grams;

19 ‘‘(E) injury prevention and safety edu20 cation programs; and

21 ‘‘(F) activities for the prevention and con22 trol of communicable diseases.

23 ‘‘(3) DUTIES OF THE SECRETARY.—The Sec24 retary of the Interior shall—
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1 ‘‘(A) provide training to teachers in com2 prehensive school health education curricula;

3 ‘‘(B) ensure the integration and coordina4 tion of school-based programs with existing

5 services and health programs available in the

6 community; and

7 ‘‘(C) encourage healthy, tobacco-free school

8 environments.

9 ‘‘SEC. 211. INDIAN YOUTH PROGRAM.

10 ‘‘(a) PROGRAM AUTHORIZED.—The Secretary, acting

11 through the Service, is authorized to establish and admin12 ister a program to provide funding to Indian Tribes, Trib13 al Organizations, and Urban Indian Organizations for in14 novative mental and physical disease prevention and

15 health promotion and treatment programs for Indian and

16 Urban Indian preadolescent and adolescent youths.

17 ‘‘(b) USE OF FUNDS.—

18 ‘‘(1) ALLOWABLE USES.—Funds made available

19 under this section may be used to—

20 ‘‘(A) develop prevention and treatment

21 programs for Indian youth which promote men22 tal and physical health and incorporate cultural

23 values, community and family involvement, and

24 traditional health care practitioners; and
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1 ‘‘(B) develop and provide community train2 ing and education.

3 ‘‘(2) PROHIBITED USE.—Funds made available

4 under this section may not be used to provide serv5 ices described in section 707(c).

6 ‘‘(c) DUTIES OF THE SECRETARY.—The Secretary

7 shall—

8 ‘‘(1) disseminate to Indian Tribes, Tribal Orga9 nizations, and Urban Indian Organizations informa10 tion regarding models for the delivery of comprehen11 sive health care services to Indian and Urban Indian

12 adolescents;

13 ‘‘(2) encourage the implementation of such

14 models; and

15 ‘‘(3) at the request of an Indian Tribe, Tribal

16 Organization, or Urban Indian Organization, provide

17 technical assistance in the implementation of such

18 models.

19 ‘‘(d) CRITERIA FOR REVIEW AND APPROVAL OF AP20 PLICATIONS.—The Secretary, in consultation with Indian

21 Tribes, Tribal Organizations, and Urban Indian Organiza22 tions, shall establish criteria for the review and approval

23 of applications or proposals under this section.
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1 ‘‘SEC. 212. PREVENTION, CONTROL, AND ELIMINATION OF

2 COMMUNICABLE AND INFECTIOUS DISEASES.

3 ‘‘(a) FUNDING AUTHORIZED.—The Secretary, acting

4 through the Service, and after consultation with Indian

5 Tribes, Tribal Organizations, Urban Indian Organiza6 tions, and the Centers for Disease Control and Prevention,

7 may make funding available to Indian Tribes, Tribal Or8 ganizations, and Urban Indian Organizations for the fol9 lowing:

10 ‘‘(1) Projects for the prevention, control, and

11 elimination of communicable and infectious diseases,

12 including tuberculosis, hepatitis, HIV, respiratory

13 syncitial virus, hanta virus, sexually transmitted dis14 eases, and H. Pylori.

15 ‘‘(2) Public information and education pro16 grams for the prevention, control, and elimination of

17 communicable and infectious diseases.

18 ‘‘(3) Education, training, and clinical skills im19 provement activities in the prevention, control, and

20 elimination of communicable and infectious diseases

21 for health professionals, including allied health pro22 fessionals.

23 ‘‘(4) Demonstration projects for the screening,

24 treatment, and prevention of hepatitis C virus

25 (HCV).
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1 ‘‘(b) APPLICATION REQUIRED.—The Secretary may

2 provide funding under subsection (a) only if an application

3 or proposal for funding is submitted to the Secretary.

4 ‘‘(c) COORDINATION WITH HEALTH AGENCIES.—In5 dian Tribes, Tribal Organizations, and Urban Indian Or6 ganizations receiving funding under this section are en7 couraged to coordinate their activities with the Centers for

8 Disease Control and Prevention and State and local health

9 agencies.

10 ‘‘(d) TECHNICAL ASSISTANCE; REPORT.—In carrying

11 out this section, the Secretary—

12 ‘‘(1) may, at the request of an Indian Tribe,

13 Tribal Organization, or Urban Indian Organization,

14 provide technical assistance; and

15 ‘‘(2) shall prepare and submit a report to Con16 gress biennially on the use of funds under this sec17 tion and on the progress made toward the preven18 tion, control, and elimination of communicable and

19 infectious diseases among Indians and Urban Indi20 ans.

21 ‘‘SEC. 213. AUTHORITY FOR PROVISION OF OTHER SERV22 ICES.

23 ‘‘(a) FUNDING AUTHORIZED.—The Secretary, acting

24 through the Service, Indian Tribes, and Tribal Organiza25 tions, may provide funding under this Act to meet the ob-
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1 jectives set forth in section 3 through health care-related

2 services and programs not otherwise described in this Act,

3 including—

4 ‘‘(1) hospice care;

5 ‘‘(2) assisted living;

6 ‘‘(3) long-term health care;

7 ‘‘(4) home- and community-based services; and

8 ‘‘(5) public health functions.

9 ‘‘(b) SERVICES TO OTHERWISE INELIGIBLE PER10 SONS.—Subject to section 807, at the discretion of the

11 Service, Indian Tribes, or Tribal Organizations, services

12 provided for hospice care, home- and community-based

13 care, assisted living, and long-term care may be provided

14 (subject to reimbursement) to persons otherwise ineligible

15 for the health care benefits of the Service. Any funds re16 ceived under this subsection shall not be used to offset

17 or limit the funding allocated to the Service or an Indian

18 Tribe or Tribal Organization.

19 ‘‘(c) DEFINITIONS.—For the purposes of this section,

20 the following definitions shall apply:

21 ‘‘(1) The term ‘home- and community-based

22 services’ means 1 or more of the following:

23 ‘‘(A) Homemaker/home health aide serv24 ices.

25 ‘‘(B) Chore services.
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1 ‘‘(C) Personal care services.

2 ‘‘(D) Nursing care services provided out3 side of a nursing facility by, or under the super4 vision of, a registered nurse.

5 ‘‘(E) Respite care.

6 ‘‘(F) Training for family members.

7 ‘‘(G) Adult day care.

8 ‘‘(H) Such other home- and community9 based services as the Secretary, an Indian tribe,

10 or a Tribal Organization may approve.

11 ‘‘(2) The term ‘hospice care’ means the items

12 and services specified in subparagraphs (A) through

13 (H) of section 1861(dd)(1) of the Social Security

14 Act (42 U.S.C. 1395x(dd)(1)), and such other serv15 ices which an Indian Tribe or Tribal Organization

16 determines are necessary and appropriate to provide

17 in furtherance of this care.

18 ‘‘(3) The term ‘public health functions’ means

19 the provision of public health-related programs,

20 functions, and services, including assessment, assur21 ance, and policy development which Indian Tribes

22 and Tribal Organizations are authorized and encour23 aged, in those circumstances where it meets their

24 needs, to do by forming collaborative relationships
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1 with all levels of local, State, and Federal Govern2 ment.

3 ‘‘SEC. 214. INDIAN WOMEN’S HEALTH CARE.

4 ‘‘The Secretary, acting through the Service and In5 dian Tribes, Tribal Organizations, and Urban Indian Or6 ganizations, shall monitor and improve the quality of

7 health care for Indian women of all ages through the plan8 ning and delivery of programs administered by the Service,

9 in order to improve and enhance the treatment models of

10 care for Indian women.

11 ‘‘SEC. 215. ENVIRONMENTAL AND NUCLEAR HEALTH HAZ12 ARDS.

13 ‘‘(a) STUDIES AND MONITORING.—The Secretary

14 and the Service shall conduct, in conjunction with other

15 appropriate Federal agencies and in consultation with con16 cerned Indian Tribes and Tribal Organizations, studies

17 and ongoing monitoring programs to determine trends in

18 the health hazards to Indian miners and to Indians on

19 or near reservations and Indian communities as a result

20 of environmental hazards which may result in chronic or

21 life threatening health problems, such as nuclear resource

22 development, petroleum contamination, and contamination

23 of water source and of the food chain. Such studies shall

24 include—
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1 ‘‘(1) an evaluation of the nature and extent of

2 health problems caused by environmental hazards

3 currently exhibited among Indians and the causes of

4 such health problems;

5 ‘‘(2) an analysis of the potential effect of ongo6 ing and future environmental resource development

7 on or near reservations and Indian communities, in8 cluding the cumulative effect over time on health;

9 ‘‘(3) an evaluation of the types and nature of

10 activities, practices, and conditions causing or affect11 ing such health problems, including uranium mining

12 and milling, uranium mine tailing deposits, nuclear

13 power plant operation and construction, and nuclear

14 waste disposal; oil and gas production or transpor15 tation on or near reservations or Indian commu16 nities; and other development that could affect the

17 health of Indians and their water supply and food

18 chain;

19 ‘‘(4) a summary of any findings and rec20 ommendations provided in Federal and State stud21 ies, reports, investigations, and inspections during

22 the 5 years prior to the date of enactment of the In23 dian Health Care Improvement Act Amendments of

24 2005 that directly or indirectly relate to the activi-
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1 ties, practices, and conditions affecting the health or

2 safety of such Indians; and

3 ‘‘(5) the efforts that have been made by Federal

4 and State agencies and resource and economic devel5 opment companies to effectively carry out an edu6 cation program for such Indians regarding the

7 health and safety hazards of such development.

8 ‘‘(b) HEALTH CARE PLANS.—Upon completion of

9 such studies, the Secretary and the Service shall take into

10 account the results of such studies and, in consultation

11 with Indian Tribes and Tribal Organizations, develop

12 health care plans to address the health problems studied

13 under subsection (a). The plans shall include—

14 ‘‘(1) methods for diagnosing and treating Indi15 ans currently exhibiting such health problems;

16 ‘‘(2) preventive care and testing for Indians

17 who may be exposed to such health hazards, includ18 ing the monitoring of the health of individuals who

19 have or may have been exposed to excessive amounts

20 of radiation or affected by other activities that have

21 had or could have a serious impact upon the health

22 of such individuals; and

23 ‘‘(3) a program of education for Indians who,

24 by reason of their work or geographic proximity to
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1 such nuclear or other development activities, may ex2 perience health problems.

3 ‘‘(c) SUBMISSION OF REPORT AND PLAN TO CON4 GRESS.—The Secretary and the Service shall submit to

5 Congress the study prepared under subsection (a) no later

6 than 18 months after the date of enactment of the Indian

7 Health Care Improvement Act Amendments of 2005. The

8 health care plan prepared under subsection (b) shall be

9 submitted in a report no later than 1 year after the study

10 prepared under subsection (a) is submitted to Congress.

11 Such report shall include recommended activities for the

12 implementation of the plan, as well as an evaluation of

13 any activities previously undertaken by the Service to ad14 dress such health problems.

15 ‘‘(d) INTERGOVERNMENTAL TASK FORCE.—

16 ‘‘(1) ESTABLISHMENT; MEMBERS.—There is es17 tablished an Intergovernmental Task Force to be

18 composed of the following individuals (or their des19 ignees):

20 ‘‘(A) The Secretary of Energy.

21 ‘‘(B) The Secretary of the Environmental

22 Protection Agency.

23 ‘‘(C) The Director of the Bureau of Mines.

24 ‘‘(D) The Assistant Secretary for Occupa25 tional Safety and Health.
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1 ‘‘(E) The Secretary of the Interior.

2 ‘‘(F) The Secretary of Health and Human

3 Services.

4 ‘‘(G) The Director of the Indian Health

5 Service.

6 ‘‘(2) DUTIES.—The Task Force shall—

7 ‘‘(A) identify existing and potential oper8 ations related to nuclear resource development

9 or other environmental hazards that affect or

10 may affect the health of Indians on or near a

11 reservation or in an Indian community; and

12 ‘‘(B) enter into activities to correct exist13 ing health hazards and ensure that current and

14 future health problems resulting from nuclear

15 resource or other development activities are

16 minimized or reduced.

17 ‘‘(3) CHAIRMAN; MEETINGS.—The Secretary of

18 Health and Human Services shall be the Chairman

19 of the Task Force. The Task Force shall meet at

20 least twice each year.

21 ‘‘(e) HEALTH SERVICES TO CERTAIN EMPLOYEES.—

22 In the case of any Indian who—

23 ‘‘(1) as a result of employment in or near a

24 uranium mine or mill or near any other environ-
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1 mental hazard, suffers from a work-related illness or

2 condition;

3 ‘‘(2) is eligible to receive diagnosis and treat4 ment services from an Indian Health Program; and

5 ‘‘(3) by reason of such Indian’s employment, is

6 entitled to medical care at the expense of such mine

7 or mill operator or entity responsible for the environ8 mental hazard, the Indian Health Program shall, at

9 the request of such Indian, render appropriate medi10 cal care to such Indian for such illness or condition

11 and may be reimbursed for any medical care so ren12 dered to which such Indian is entitled at the expense

13 of such operator or entity from such operator or en14 tity. Nothing in this subsection shall affect the

15 rights of such Indian to recover damages other than

16 such amounts paid to the Indian Health Program

17 from the employer for providing medical care for

18 such illness or condition.

19 ‘‘SEC. 216. ARIZONA AS A CONTRACT HEALTH SERVICE DE20 LIVERY AREA.

21 ‘‘(a) IN GENERAL.—For fiscal years beginning with

22 the fiscal year ending September 30, 1983, and ending

23 with the fiscal year ending September 30, 2015, the State

24 of Arizona shall be designated as a contract health service

25 delivery area by the Service for the purpose of providing
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1 contract health care services to members of federally rec2 ognized Indian Tribes of Arizona.

3 ‘‘(b) MAINTENANCE OF SERVICES.—The Service

4 shall not curtail any health care services provided to Indi5 ans residing on reservations in the State of Arizona if such

6 curtailment is due to the provision of contract services in

7 such State pursuant to the designation of such State as

8 a contract health service delivery area pursuant to sub9 section (a).

10 ‘‘SEC. 216A. NORTH DAKOTA AND SOUTH DAKOTA AS CON11 TRACT HEALTH SERVICE DELIVERY AREA.

12 ‘‘(a) IN GENERAL.—Beginning in fiscal year 2003,

13 the States of North Dakota and South Dakota shall be

14 designated as a contract health service delivery area by

15 the Service for the purpose of providing contract health

16 care services to members of federally recognized Indian

17 Tribes of North Dakota and South Dakota.

18 ‘‘(b) LIMITATION.—The Service shall not curtail any

19 health care services provided to Indians residing on any

20 reservation, or in any county that has a common boundary

21 with any reservation, in the State of North Dakota or

22 South Dakota if such curtailment is due to the provision

23 of contract services in such States pursuant to the des24 ignation of such States as a contract health service deliv25 ery area pursuant to subsection (a).
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1 ‘‘SEC. 217. CALIFORNIA CONTRACT HEALTH SERVICES PRO2 GRAM.

3 ‘‘(a) FUNDING AUTHORIZED.—The Secretary is au4 thorized to fund a program using the California Rural In5 dian Health Board (hereafter in this section referred to

6 as the ‘CRIHB’) as a contract care intermediary to im7 prove the accessibility of health services to California Indi8 ans.

9 ‘‘(b) REIMBURSEMENT CONTRACT.—The Secretary

10 shall enter into an agreement with the CRIHB to reim11 burse the CRIHB for costs (including reasonable adminis12 trative costs) incurred pursuant to this section, in provid13 ing medical treatment under contract to California Indi14 ans described in section 806(a) throughout the California

15 contract health services delivery area described in section

16 218 with respect to high cost contract care cases.

17 ‘‘(c) ADMINISTRATIVE EXPENSES.—Not more than 5

18 percent of the amounts provided to the CRIHB under this

19 section for any fiscal year may be for reimbursement for

20 administrative expenses incurred by the CRIHB during

21 such fiscal year.

22 ‘‘(d) LIMITATION ON PAYMENT.—No payment may

23 be made for treatment provided hereunder to the extent

24 payment may be made for such treatment under the In25 dian Catastrophic Health Emergency Fund described in

26 section 202 or from amounts appropriated or otherwise
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1 made available to the California contract health service de2 livery area for a fiscal year.

3 ‘‘(e) ADVISORY BOARD.—There is established an ad4 visory board which shall advise the CRIHB in carrying

5 out this section. The advisory board shall be composed of

6 representatives, selected by the CRIHB, from not less

7 than 8 Tribal Health Programs serving California Indians

8 covered under this section at least one half of whom of

9 whom are not affiliated with the CRIHB.

10 ‘‘SEC. 218. CALIFORNIA AS A CONTRACT HEALTH SERVICE

11 DELIVERY AREA.

12 ‘‘The State of California, excluding the counties of

13 Alameda, Contra Costa, Los Angeles, Marin, Orange, Sac14 ramento, San Francisco, San Mateo, Santa Clara, Kern,

15 Merced, Monterey, Napa, San Benito, San Joaquin, San

16 Luis Obispo, Santa Cruz, Solano, Stanislaus, and Ven17 tura, shall be designated as a contract health service deliv18 ery area by the Service for the purpose of providing con19 tract health services to California Indians. However, any

20 of the counties listed herein may only be included in the

21 contract health services delivery area if funding is specifi22 cally provided by the Service for such services in those

23 counties.
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1 ‘‘SEC. 219. CONTRACT HEALTH SERVICES FOR THE TREN2 TON SERVICE AREA.

3 ‘‘(a) AUTHORIZATION FOR SERVICES.—The Sec4 retary, acting through the Service, is directed to provide

5 contract health services to members of the Turtle Moun6 tain Band of Chippewa Indians that reside in the Trenton

7 Service Area of Divide, McKenzie, and Williams counties

8 in the State of North Dakota and the adjoining counties

9 of Richland, Roosevelt, and Sheridan in the State of Mon10 tana.

11 ‘‘(b) NO EXPANSION OF ELIGIBILITY.—Nothing in

12 this section may be construed as expanding the eligibility

13 of members of the Turtle Mountain Band of Chippewa In14 dians for health services provided by the Service beyond

15 the scope of eligibility for such health services that applied

16 on May 1, 1986.

17 ‘‘SEC. 220. PROGRAMS OPERATED BY INDIAN TRIBES AND

18 TRIBAL ORGANIZATIONS.

19 ‘‘The Service shall provide funds for health care pro20 grams and facilities operated by Tribal Health Programs

21 on the same basis as such funds are provided to programs

22 and facilities operated directly by the Service.

23 ‘‘SEC. 221. LICENSING.

24 ‘‘Health care professionals employed by a Tribal

25 Health Program shall, if licensed in any State, be exempt

26 from the licensing requirements of the State in which the
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1 Tribal Health Program performs the services described in

2 its contract or compact under the Indian Self-Determina3 tion and Education Assistance Act (25 U.S.C. 450 et

4 seq.).

5 ‘‘SEC. 222. NOTIFICATION OF PROVISION OF EMERGENCY

6 CONTRACT HEALTH SERVICES.

7 ‘‘With respect to an elderly Indian or an Indian with

8 a disability receiving emergency medical care or services

9 from a non-Service provider or in a non-Service facility

10 under the authority of this Act, the time limitation (as

11 a condition of payment) for notifying the Service of such

12 treatment or admission shall be 30 days.

13 ‘‘SEC. 223. PROMPT ACTION ON PAYMENT OF CLAIMS.

14 ‘‘(a) DEADLINE FOR RESPONSE.—The Service shall

15 respond to a notification of a claim by a provider of a

16 contract care service with either an individual purchase

17 order or a denial of the claim within 5 working days after

18 the receipt of such notification.

19 ‘‘(b) EFFECT OF UNTIMELY RESPONSE.—If the

20 Service fails to respond to a notification of a claim in ac21 cordance with subsection (a), the Service shall accept as

22 valid the claim submitted by the provider of a contract

23 care service.
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1 ‘‘(c) DEADLINE FOR PAYMENT OF VALID CLAIM.—

2 The Service shall pay a valid contract care service claim

3 within 30 days after the completion of the claim.

4 ‘‘SEC. 224. LIABILITY FOR PAYMENT.

5 ‘‘(a) NO PATIENT LIABILITY.—A patient who re6 ceives contract health care services that are authorized by

7 the Service shall not be liable for the payment of any

8 charges or costs associated with the provision of such serv9 ices.

10 ‘‘(b) NOTIFICATION.—The Secretary shall notify a

11 contract care provider and any patient who receives con12 tract health care services authorized by the Service that

13 such patient is not liable for the payment of any charges

14 or costs associated with the provision of such services not

15 later than 5 business days after receipt of a notification

16 of a claim by a provider of contract care services.

17 ‘‘(c) NO RECOURSE.—Following receipt of the notice

18 provided under subsection (b), or, if a claim has been

19 deemed accepted under section 223(b), the provider shall

20 have no further recourse against the patient who received

21 the services.

22 ‘‘SEC. 225. AUTHORIZATION OF APPROPRIATIONS.

23 ‘‘There are authorized to be appropriated such sums

24 as may be necessary for each fiscal year through fiscal

25 year 2015 to carry out this title.
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1 ‘‘TITLE III—FACILITIES

2 ‘‘SEC. 301. CONSULTATION: CONSTRUCTION AND RENOVA3 TION OF FACILITIES; REPORTS.

4 ‘‘(a) PREREQUISITES FOR EXPENDITURE OF

5 FUNDS.—Prior to the expenditure of, or the making of

6 any binding commitment to expend, any funds appro7 priated for the planning, design, construction, or renova8 tion of facilities pursuant to the Act of November 2, 1921

9 (25 U.S.C. 13) (commonly known as the ‘Snyder Act’),

10 the Secretary, acting through the Service, shall—

11 ‘‘(1) consult with any Indian Tribe that would

12 be significantly affected by such expenditure for the

13 purpose of determining and, whenever practicable,

14 honoring tribal preferences concerning size, location,

15 type, and other characteristics of any facility on

16 which such expenditure is to be made; and

17 ‘‘(2) ensure, whenever practicable and applica18 ble, that such facility meets the construction stand19 ards of any accrediting body recognized by the Sec20 retary for the purposes of the medicare, medicaid,

21 and SCHIP programs under titles XVIII, XIX, and

22 XXI of the Social Security Act by not later than 1

23 year after the date on which the construction or ren24 ovation of such facility is completed.

25 ‘‘(b) CLOSURES.—
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1 ‘‘(1) EVALUATION REQUIRED.—Notwithstand2 ing any other provision of law, no facility operated

3 by the Service may be closed if the Secretary has not

4 submitted to Congress at least 1 year prior to the

5 date of the proposed closure an evaluation of the im6 pact of the proposed closure which specifies, in addi7 tion to other considerations—

8 ‘‘(A) the accessibility of alternative health

9 care resources for the population served by such

10 facility;

11 ‘‘(B) the cost-effectiveness of such closure;

12 ‘‘(C) the quality of health care to be pro13 vided to the population served by such facility

14 after such closure;

15 ‘‘(D) the availability of contract health

16 care funds to maintain existing levels of service;

17 ‘‘(E) the views of the Indian Tribes served

18 by such facility concerning such closure;

19 ‘‘(F) the level of use of such facility by all

20 eligible Indians; and

21 ‘‘(G) the distance between such facility and

22 the nearest operating Service hospital.

23 ‘‘(2) EXCEPTION FOR CERTAIN TEMPORARY

24 CLOSURES.—Paragraph (1) shall not apply to any

25 temporary closure of a facility or any portion of a
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1 facility if such closure is necessary for medical, envi2 ronmental, or construction safety reasons.

3 ‘‘(c) HEALTH CARE FACILITY PRIORITY SYSTEM.—

4 ‘‘(1) IN GENERAL.—

5 ‘‘(A) ESTABLISHMENT.—The Secretary,

6 acting through the Service, shall establish a

7 health care facility priority system, which

8 shall—

9 ‘‘(i) be developed with Indian Tribes

10 and Tribal Organizations through nego11 tiated rulemaking under section 802;

12 ‘‘(ii) give Indian Tribes’ needs the

13 highest priority; and

14 ‘‘(iii) at a minimum, include the lists

15 required in paragraph (2)(B) and the

16 methodology required in paragraph (2)(E).

17 ‘‘(B) PRIORITY OF CERTAIN PROJECTS

18 PROTECTED.—The priority of any project estab19 lished under the construction priority system in

20 effect on the date of the Indian Health Care

21 Improvement Act Amendments of 2005 shall

22 not be affected by any change in the construc23 tion priority system taking place thereafter if

24 the project was identified as 1 of the 10 top25 priority inpatient projects, 1 of the 10 top-pri-
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1 ority outpatient projects, 1 of the 10 top-prior2 ity staff quarters developments, or 1 of the 10

3 top-priority Youth Regional Treatment Centers

4 in the fiscal year 2005 Indian Health Service

5 budget justification, or if the project had com6 pleted both Phase I and Phase II of the con7 struction priority system in effect on the date

8 of enactment of such Act.

9 ‘‘(2) REPORT; CONTENTS.—The Secretary shall

10 submit to the President, for inclusion in each report

11 required to be transmitted to Congress under section

12 801, a report which sets forth the following:

13 ‘‘(A) A description of the health care facil14 ity priority system of the Service, established

15 under paragraph (1).

16 ‘‘(B) Health care facilities lists,

17 including—

18 ‘‘(i) the 10 top-priority inpatient

19 health care facilities;

20 ‘‘(ii) the 10 top-priority outpatient

21 health care facilities;

22 ‘‘(iii) the 10 top-priority specialized

23 health care facilities (such as long-term

24 care and alcohol and drug abuse treat25 ment);
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1 ‘‘(iv) the 10 top-priority staff quarters

2 developments associated with health care

3 facilities; and

4 ‘‘(v) the 10 top-priority hostels associ5 ated with health care facilities.

6 ‘‘(C) The justification for such order of

7 priority.

8 ‘‘(D) The projected cost of such projects.

9 ‘‘(E) The methodology adopted by the

10 Service in establishing priorities under its

11 health care facility priority system.

12 ‘‘(3) REQUIREMENTS FOR PREPARATION OF RE13 PORTS.—In preparing each report required under

14 paragraph (2) (other than the initial report), the

15 Secretary shall annually—

16 ‘‘(A) consult with and obtain information

17 on all health care facilities needs from Indian

18 Tribes, Tribal Organizations, and Urban Indian

19 Organizations; and

20 ‘‘(B) review the total unmet needs of all

21 Indian Tribes, Tribal Organizations, and Urban

22 Indian Organizations for health care facilities

23 (including hostels and staff quarters), including

24 needs for renovation and expansion of existing

25 facilities.
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1 ‘‘(4) CRITERIA FOR EVALUATING NEEDS.—For

2 purposes of this subsection, the Secretary shall, in

3 evaluating the needs of facilities operated under any

4 contract or compact under the Indian Self-Deter5 mination and Education Assistance Act (25 U.S.C.

6 450 et seq.) use the same criteria that the Secretary

7 uses in evaluating the needs of facilities operated di8 rectly by the Service.

9 ‘‘(5) NEEDS OF FACILITIES UNDER ISDEAA

10 AGREEMENTS.—The Secretary shall ensure that the

11 planning, design, construction, and renovation needs

12 of Service and non-Service facilities operated under

13 contracts or compacts in accordance with the Indian

14 Self-Determination and Education Assistance Act

15 (25 U.S.C. 450 et seq.) are fully and equitably inte16 grated into the health care facility priority system.

17 ‘‘(d) REVIEW OF NEED FOR FACILITIES.—

18 ‘‘(1) INITIAL REPORT.—In the year 2006, the

19 Government Accountability Office shall prepare and

20 finalize a report which sets forth the needs of the

21 Service, Indian Tribes, Tribal Organizations, and

22 Urban Indian Organizations, for the facilities listed

23 under subsection (c)(2)(B), including the needs for

24 renovation and expansion of existing facilities. The

25 Government Accountability Office shall submit the
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1 report to the appropriate authorizing and appropria2 tions committees of Congress and to the Secretary.

3 ‘‘(2) Beginning in the year 2006, the Secretary

4 shall update the report required under paragraph

5 (1) every 5 years.

6 ‘‘(3) The Comptroller General and the Sec7 retary shall consult with Indian Tribes, Tribal Orga8 nizations, and Urban Indian Organizations. The

9 Secretary shall submit the reports required by para10 graphs (1) and (2), to the President for inclusion in

11 the report required to be transmitted to Congress

12 under section 801.

13 ‘‘(4) For purposes of this subsection, the re14 ports shall, regarding the needs of facilities operated

15 under any contract or compact under the Indian

16 Self-Determination and Education Assistance Act

17 (25 U.S.C. 450 et seq.), be based on the same cri18 teria that the Secretary uses in evaluating the needs

19 of facilities operated directly by the Service.

20 ‘‘(5) The planning, design, construction, and

21 renovation needs of facilities operated under con22 tracts or compacts under the Indian Self-Determina23 tion and Education Assistance Act (25 U.S.C. 450

24 et seq.) shall be fully and equitably integrated into
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1 the development of the health facility priority sys2 tem.

3 ‘‘(6) Beginning in 2007 and each fiscal year

4 thereafter, the Secretary shall provide an oppor5 tunity for nomination of planning, design, and con6 struction projects by the Service, Indian Tribes,

7 Tribal Organizations, and Urban Indian Organiza8 tions for consideration under the health care facility

9 priority system.

10 ‘‘(e) FUNDING CONDITION.—All funds appropriated

11 under the Act of November 2, 1921 (25 U.S.C. 13) (com12 monly known as the ‘Snyder Act’), for the planning, de13 sign, construction, or renovation of health facilities for the

14 benefit of 1 or more Indian Tribes shall be subject to the

15 provisions of the Indian Self-Determination and Edu16 cation Assistance Act (25 U.S.C. 450 et seq.).

17 ‘‘(f) DEVELOPMENT OF INNOVATIVE APPROACHES.—

18 The Secretary shall consult and cooperate with Indian

19 Tribes, Tribal Organizations, and Urban Indian Organiza20 tions in developing innovative approaches to address all

21 or part of the total unmet need for construction of health

22 facilities, including those provided for in other sections of

23 this title and other approaches.

24 ‘‘SEC. 302. SANITATION FACILITIES.

25 ‘‘(a) FINDINGS.—Congress finds the following:
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1 ‘‘(1) The provision of sanitation facilities is pri2 marily a health consideration and function.

3 ‘‘(2) Indian people suffer an inordinately high

4 incidence of disease, injury, and illness directly at5 tributable to the absence or inadequacy of sanitation

6 facilities.

7 ‘‘(3) The long-term cost to the United States of

8 treating and curing such disease, injury, and illness

9 is substantially greater than the short-term cost of

10 providing sanitation facilities and other preventive

11 health measures.

12 ‘‘(4) Many Indian homes and Indian commu13 nities still lack sanitation facilities.

14 ‘‘(5) It is in the interest of the United States,

15 and it is the policy of the United States, that all In16 dian communities and Indian homes, new and exist17 ing, be provided with sanitation facilities.

18 ‘‘(b) FACILITIES AND SERVICES.—In furtherance of

19 the findings made in subsection (a), Congress reaffirms

20 the primary responsibility and authority of the Service to

21 provide the necessary sanitation facilities and services as

22 provided in section 7 of the Act of August 5, 1954 (42

23 U.S.C. 2004a). Under such authority, the Secretary, act24 ing through the Service, is authorized to provide the fol25 lowing:
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1 ‘‘(1) Financial and technical assistance to In2 dian Tribes, Tribal Organizations, and Indian com3 munities in the establishment, training, and equip4 ping of utility organizations to operate and maintain

5 sanitation facilities, including the provision of exist6 ing plans, standard details, and specifications avail7 able in the Department, to be used at the option of

8 the Indian Tribe, Tribal Organization, or Indian

9 community.

10 ‘‘(2) Ongoing technical assistance and training

11 to Indian Tribes, Tribal Organizations, and Indian

12 communities in the management of utility organiza13 tions which operate and maintain sanitation facili14 ties.

15 ‘‘(3) Priority funding for operation and mainte16 nance assistance for, and emergency repairs to, sani17 tation facilities operated by an Indian Tribe, Tribal

18 Organization or Indian community when necessary

19 to avoid an imminent health threat or to protect the

20 investment in sanitation facilities and the investment

21 in the health benefits gained through the provision

22 of sanitation facilities.

23 ‘‘(c) FUNDING.—Notwithstanding any other provi24 sion of law—
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1 ‘‘(1) the Secretary of Housing and Urban De2 velopment is authorized to transfer funds appro3 priated under the Native American Housing Assist4 ance and Self-Determination Act of 1996 to the Sec5 retary of Health and Human Services;

6 ‘‘(2) the Secretary of Health and Human Serv7 ices is authorized to accept and use such funds for

8 the purpose of providing sanitation facilities and

9 services for Indians under section 7 of the Act of

10 August 5, 1954 (42 U.S.C. 2004a);

11 ‘‘(3) unless specifically authorized when funds

12 are appropriated, the Secretary shall not use funds

13 appropriated under section 7 of the Act of August

14 5, 1954 (42 U.S.C. 2004a), to provide sanitation fa15 cilities to new homes constructed using funds pro16 vided by the Department of Housing and Urban De17 velopment;

18 ‘‘(4) the Secretary of Health and Human Serv19 ices is authorized to accept from any source, includ20 ing Federal and State agencies, funds for the pur21 pose of providing sanitation facilities and services

22 and place these funds into contracts or compacts

23 under the Indian Self-Determination and Education

24 Assistance Act (25 U.S.C. 450 et seq.);
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1 ‘‘(5) except as otherwise prohibited by this sec2 tion, the Secretary may use funds appropriated

3 under the authority of section 7 of the Act of Au4 gust 5, 1954 (42 U.S.C. 2004a) to fund up to 100

5 percent of the amount of an Indian Tribe’s loan ob6 tained under any Federal program for new projects

7 to construct eligible sanitation facilities to serve In8 dian homes;

9 ‘‘(6) except as otherwise prohibited by this sec10 tion, the Secretary may use funds appropriated

11 under the authority of section 7 of the Act of Au12 gust 5, 1954 (42 U.S.C. 2004a) to meet matching

13 or cost participation requirements under other Fed14 eral and non-Federal programs for new projects to

15 construct eligible sanitation facilities;

16 ‘‘(7) all Federal agencies are authorized to

17 transfer to the Secretary funds identified, granted,

18 loaned, or appropriated whereby the Department’s

19 applicable policies, rules, and regulations shall apply

20 in the implementation of such projects;

21 ‘‘(8) the Secretary of Health and Human Serv22 ices shall enter into interagency agreements with

23 Federal and State agencies for the purpose of pro24 viding financial assistance for sanitation facilities

25 and services under this Act; and
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1 ‘‘(9) the Secretary of Health and Human Serv2 ices shall, by regulation developed through rule3 making under section 802, establish standards appli4 cable to the planning, design, and construction of

5 sanitation facilities funded under this Act.

6 ‘‘(d) CERTAIN CAPABILITIES NOT PREREQUISITE.—

7 The financial and technical capability of an Indian Tribe,

8 Tribal Organization, or Indian community to safely oper9 ate, manage, and maintain a sanitation facility shall not

10 be a prerequisite to the provision or construction of sanita11 tion facilities by the Secretary.

12 ‘‘(e) FINANCIAL ASSISTANCE.—The Secretary is au13 thorized to provide financial assistance to Indian Tribes,

14 Tribal Organizations, and Indian communities for oper15 ation, management, and maintenance of their sanitation

16 facilities.

17 ‘‘(f) OPERATION, MANAGEMENT, AND MAINTENANCE

18 OF FACILITIES.—The Indian Tribe has the primary re19 sponsibility to establish, collect, and use reasonable user

20 fees, or otherwise set aside funding, for the purpose of

21 operating, managing, and maintaining sanitation facilities.

22 If a sanitation facility serving a community that is oper23 ated by an Indian Tribe or Tribal Organization is threat24 ened with imminent failure and such operator lacks capac25 ity to maintain the integrity or the health benefits of the
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1 sanitation facility, then the Secretary is authorized to as2 sist the Indian Tribe, Tribal Organization, or Indian com3 munity in the resolution of the problem on a short-term

4 basis through cooperation with the emergency coordinator

5 or by providing operation, management, and maintenance

6 service.

7 ‘‘(g) ISDEAA PROGRAM FUNDED ON EQUAL

8 BASIS.—Tribal Health Programs shall be eligible (on an

9 equal basis with programs that are administered directly

10 by the Service) for—

11 ‘‘(1) any funds appropriated pursuant to this

12 section; and

13 ‘‘(2) any funds appropriated for the purpose of

14 providing sanitation facilities.

15 ‘‘(h) REPORT.—

16 ‘‘(1) REQUIRED; CONTENTS.—The Secretary, in

17 consultation with the Secretary of Housing and

18 Urban Development, Indian Tribes, Tribal Organiza19 tions, and tribally designated housing entities (as de20 fined in section 4 of the Native American Housing

21 Assistance and Self-Determination Act of 1996 (25

22 U.S.C. 4103)) shall submit to the President, for in23 clusion in each report required to be transmitted to

24 Congress under section 801, a report which sets

25 forth—
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1 ‘‘(A) the current Indian sanitation facility

2 priority system of the Service;

3 ‘‘(B) the methodology for determining

4 sanitation deficiencies and needs;

5 ‘‘(C) the level of initial and final sanitation

6 deficiency for each type of sanitation facility for

7 each project of each Indian Tribe or Indian

8 community;

9 ‘‘(D) the amount and most effective use of

10 funds, derived from whatever source, necessary

11 to accommodate the sanitation facilities needs

12 of new homes assisted with funds under the

13 Native American Housing Assistance and Self14 Determination Act, and to reduce the identified

15 sanitation deficiency levels of all Indian Tribes

16 and Indian communities to level I sanitation de17 ficiency as defined in paragraph (4)(A); and

18 ‘‘(E) a 10-year plan to provide sanitation

19 facilities to serve existing Indian homes and In20 dian communities and new and renovated In21 dian homes.

22 ‘‘(2) CRITERIA.—The criteria on which the defi23 ciencies and needs will be evaluated shall be devel24 oped through negotiated rulemaking pursuant to

25 section 802.
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1 ‘‘(3) UNIFORM METHODOLOGY.—The methodol2 ogy used by the Secretary in determining, preparing

3 cost estimates for, and reporting sanitation defi4 ciencies for purposes of paragraph (1) shall be ap5 plied uniformly to all Indian Tribes and Indian com6 munities.

7 ‘‘(4) SANITATION DEFICIENCY LEVELS.—For

8 purposes of this subsection, the sanitation deficiency

9 levels for an individual, Indian Tribe, or Indian com10 munity sanitation facility to serve Indian homes are

11 determined as follows:

12 ‘‘(A) A level I deficiency exists if a sanita13 tion facility serving an individual, Indian Tribe,

14 or Indian community—

15 ‘‘(i) complies with all applicable water

16 supply, pollution control, and solid waste

17 disposal laws; and

18 ‘‘(ii) deficiencies relate to routine re19 placement, repair, or maintenance needs.

20 ‘‘(B) A level II deficiency exists if a sanita21 tion facility serving an individual, Indian Tribe,

22 or Indian community substantially or recently

23 complied with all applicable water supply, pollu24 tion control, and solid waste laws and any defi25 ciencies relate to—
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1 ‘‘(i) small or minor capital improve2 ments needed to bring the facility back

3 into compliance;

4 ‘‘(ii) capital improvements that are

5 necessary to enlarge or improve the facili6 ties in order to meet the current needs for

7 domestic sanitation facilities; or

8 ‘‘(iii) the lack of equipment or train9 ing by an Indian Tribe, Tribal Organiza10 tion, or an Indian community to properly

11 operate and maintain the sanitation facili12 ties.

13 ‘‘(C) A level III deficiency exists if a sani14 tation facility serving an individual, Indian

15 Tribe or Indian community meets one or more

16 of the following conditions—

17 ‘‘(i) water or sewer service in the

18 home is provided by a haul system with

19 holding tanks and interior plumbing;

20 ‘‘(ii) major significant interruptions to

21 water supply or sewage disposal occur fre22 quently, requiring major capital improve23 ments to correct the deficiencies; or
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1 ‘‘(iii) there is no access to or no ap2 proved or permitted solid waste facility

3 available.

4 ‘‘(D) A level IV deficiency exists if—

5 ‘‘(i) a sanitation facility of an individ6 ual, Indian Tribe, Tribal Organization, or

7 Indian community has no piped water or

8 sewer facilities in the home or the facility

9 has become inoperable due to major com10 ponent failure; or

11 ‘‘(ii) where only a washeteria or cen12 tral facility exists in the community.

13 ‘‘(E) A level V deficiency exists in the ab14 sence of a sanitation facility, where individual

15 homes do not have access to safe drinking

16 water or adequate wastewater (including sew17 age) disposal.

18 ‘‘(i) DEFINITIONS.—For purposes of this section, the

19 following terms apply:

20 ‘‘(1) INDIAN COMMUNITY.—The term ‘Indian

21 community’ means a geographic area, a significant

22 proportion of whose inhabitants are Indians and

23 which is served by or capable of being served by a

24 facility described in this section.
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1 ‘‘(2) SANITATION FACILITIES.—The terms

2 ‘sanitation facility’ and ‘sanitation facilities’ mean

3 safe and adequate water supply systems, sanitary

4 sewage disposal systems, and sanitary solid waste

5 systems (and all related equipment and support in6 frastructure).

7 ‘‘SEC. 303. PREFERENCE TO INDIANS AND INDIAN FIRMS.

8 ‘‘(a) BUY INDIAN ACT.—The Secretary, acting

9 through the Service, may use the negotiating authority of

10 section 23 of the Act of June 25, 1910 (25 U.S.C. 47,

11 commonly known as the ‘Buy Indian Act’), to give pref12 erence to any Indian or any enterprise, partnership, cor13 poration, or other type of business organization owned and

14 controlled by an Indian or Indians including former or

15 currently federally recognized Indian Tribes in the State

16 of New York (hereinafter referred to as an ‘Indian firm’)

17 in the construction and renovation of Service facilities pur18 suant to section 301 and in the construction of sanitation

19 facilities pursuant to section 302. Such preference may be

20 accorded by the Secretary unless the Secretary finds, pur21 suant to regulations adopted pursuant to section 802, that

22 the project or function to be contracted for will not be

23 satisfactory or such project or function cannot be properly

24 completed or maintained under the proposed contract. The

25 Secretary, in arriving at such a finding, shall consider
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1 whether the Indian or Indian firm will be deficient with

2 respect to—

3 ‘‘(1) ownership and control by Indians;

4 ‘‘(2) equipment;

5 ‘‘(3) bookkeeping and accounting procedures;

6 ‘‘(4) substantive knowledge of the project or

7 function to be contracted for;

8 ‘‘(5) adequately trained personnel; or

9 ‘‘(6) other necessary components of contract

10 performance.

11 ‘‘(b) LABOR STANDARDS.—

12 ‘‘(1) IN GENERAL.—For the purposes of imple13 menting the provisions of this title, contracts for the

14 construction or renovation of health care facilities,

15 staff quarters, and sanitation facilities, and related

16 support infrastructure, funded in whole or in part

17 with funds made available pursuant to this title,

18 shall contain a provision requiring compliance with

19 subchapter IV of chapter 31 of title 40, United

20 States Code (commonly known as the ‘Davis-Bacon

21 Act’), unless such construction or renovation—

22 ‘‘(A) is performed by a contractor pursu23 ant to a contract with an Indian Tribe or Trib24 al Organization with funds supplied through a

25 contract or compact authorized by the Indian
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1 Self-Determination and Education Assistance

2 Act, or other statutory authority; and

3 ‘‘(B) is subject to prevailing wage rates for

4 similar construction or renovation in the locality

5 as determined by the Indian Tribes or Tribal

6 Organizations to be served by the construction

7 or renovation.

8 ‘‘(2) EXCEPTION.—This subsection shall not

9 apply to construction or renovation carried out by an

10 Indian Tribe or Tribal Organization with its own

11 employees.

12 ‘‘SEC. 304. EXPENDITURE OF NONSERVICE FUNDS FOR REN13 OVATION.

14 ‘‘(a) IN GENERAL.—Notwithstanding any other pro15 vision of law, if the requirements of subsection (c) are met,

16 the Secretary, acting through the Service, is authorized

17 to accept any major expansion, renovation, or moderniza18 tion by any Indian Tribe or Tribal Organization of any

19 Service facility or of any other Indian health facility oper20 ated pursuant to a contract or compact under the Indian

21 Self-Determination and Education Assistance Act (25

22 U.S.C. 450 et seq.), including—

23 ‘‘(1) any plans or designs for such expansion,

24 renovation, or modernization; and
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1 ‘‘(2) any expansion, renovation, or moderniza2 tion for which funds appropriated under any Federal

3 law were lawfully expended.

4 ‘‘(b) PRIORITY LIST.—

5 ‘‘(1) IN GENERAL.—The Secretary shall main6 tain a separate priority list to address the needs for

7 increased operating expenses, personnel, or equip8 ment for such facilities. The methodology for estab9 lishing priorities shall be developed through nego10 tiated rulemaking under section 802. The list of pri11 ority facilities will be revised annually in consulta12 tion with Indian Tribes and Tribal Organizations.

13 ‘‘(2) REPORT.—The Secretary shall submit to

14 the President, for inclusion in each report required

15 to be transmitted to Congress under section 801, the

16 priority list maintained pursuant to paragraph (1).

17 ‘‘(c) REQUIREMENTS.—The requirements of this sub18 section are met with respect to any expansion, renovation,

19 or modernization if—

20 ‘‘(1) the Indian Tribe or Tribal Organization—

21 ‘‘(A) provides notice to the Secretary of its

22 intent to expand, renovate, or modernize; and

23 ‘‘(B) applies to the Secretary to be placed

24 on a separate priority list to address the needs
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1 of such new facilities for increased operating ex2 penses, personnel, or equipment; and

3 ‘‘(2) the expansion, renovation, or

4 modernization—

5 ‘‘(A) is approved by the appropriate area

6 director of the Service for Federal facilities; and

7 ‘‘(B) is administered by the Indian Tribe

8 or Tribal Organization in accordance with any

9 applicable regulations prescribed by the Sec10 retary with respect to construction or renova11 tion of Service facilities.

12 ‘‘(d) ADDITIONAL REQUIREMENT FOR EXPANSION.—

13 In addition to the requirements under subsection (c), for

14 any expansion, the Indian Tribe or Tribal Organization

15 shall provide to the Secretary additional information devel16 oped through negotiated rulemaking under section 802,

17 including additional staffing, equipment, and other costs

18 associated with the expansion.

19 ‘‘(e) CLOSURE OR CONVERSION OF FACILITIES.—If

20 any Service facility which has been expanded, renovated,

21 or modernized by an Indian Tribe or Tribal Organization

22 under this section ceases to be used as a Service facility

23 during the 20-year period beginning on the date such ex24 pansion, renovation, or modernization is completed, such

25 Indian Tribe or Tribal Organization shall be entitled to
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1 recover from the United States an amount which bears

2 the same ratio to the value of such facility at the time

3 of such cessation as the value of such expansion, renova4 tion, or modernization (less the total amount of any funds

5 provided specifically for such facility under any Federal

6 program that were expended for such expansion, renova7 tion, or modernization) bore to the value of such facility

8 at the time of the completion of such expansion, renova9 tion, or modernization.

10 ‘‘SEC. 305. FUNDING FOR THE CONSTRUCTION, EXPANSION,

11 AND MODERNIZATION OF SMALL AMBULA12 TORY CARE FACILITIES.

13 ‘‘(a) FUNDING.—

14 ‘‘(1) IN GENERAL.—The Secretary, acting

15 through the Service, in consultation with Indian

16 Tribes and Tribal Organizations, shall make grants

17 to Indian Tribes and Tribal Organizations for the

18 construction, expansion, or modernization of facili19 ties for the provision of ambulatory care services to

20 eligible Indians (and noneligible persons pursuant to

21 subsections (b)(2) and (c)(1)(C)). Funding made

22 under this section may cover up to 100 percent of

23 the costs of such construction, expansion, or mod24 ernization. For the purposes of this section, the term
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1 ‘construction’ includes the replacement of an exist2 ing facility.

3 ‘‘(2) AGREEMENT REQUIRED.—Funding under

4 paragraph (1) may only be made available to a Trib5 al Health Program operating an Indian health facil6 ity (other than a facility owned or constructed by

7 the Service, including a facility originally owned or

8 constructed by the Service and transferred to an In9 dian Tribe or Tribal Organization).

10 ‘‘(b) USE OF FUNDS.—

11 ‘‘(1) ALLOWABLE USES.—Funding provided

12 under this section may be used for the construction,

13 expansion, or modernization (including the planning

14 and design of such construction, expansion, or mod15 ernization) of an ambulatory care facility—

16 ‘‘(A) located apart from a hospital;

17 ‘‘(B) not funded under section 301 or sec18 tion 307; and

19 ‘‘(C) which, upon completion of such con20 struction or modernization will—

21 ‘‘(i) have a total capacity appropriate

22 to its projected service population;

23 ‘‘(ii) provide annually no fewer than

24 150 patient visits by eligible Indians and

25 other users who are eligible for services in
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1 such facility in accordance with section

2 807(c)(2); and

3 ‘‘(iii) provide ambulatory care in a

4 Service Area (specified in the contract or

5 compact under the Indian Self-Determina6 tion and Education Assistance Act (25

7 U.S.C. 450 et seq.)) with a population of

8 no fewer than 1,500 eligible Indians and

9 other users who are eligible for services in

10 such facility in accordance with section

11 807(c)(2).

12 ‘‘(2) ADDITIONAL ALLOWABLE USE.—The Sec13 retary may also reserve a portion of the funding pro14 vided under this section and use those reserved

15 funds to reduce an outstanding debt incurred by In16 dian Tribes or Tribal Organizations for the con17 struction, expansion, or modernization of an ambula18 tory care facility that meets the requirements under

19 paragraph (1). The provisions of this section shall

20 apply, except that such applications for funding

21 under this paragraph shall be considered separately

22 from applications for funding under paragraph (1).

23 ‘‘(3) USE ONLY FOR CERTAIN PORTION OF

24 COSTS.—Funding provided under this section may

25 be used only for the cost of that portion of a con-
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1 struction, expansion, or modernization project that

2 benefits the Service population identified above in

3 subsection (b)(1)(C) (ii) and (iii). The requirements

4 of clauses (ii) and (iii) of paragraph (1)(C) shall not

5 apply to an Indian Tribe or Tribal Organization ap6 plying for funding under this section for a health

7 care facility located or to be constructed on an is8 land or when such facility is not located on a road

9 system providing direct access to an inpatient hos10 pital where care is available to the Service popu11 lation.

12 ‘‘(c) FUNDING.—

13 ‘‘(1) APPLICATION.—No funding may be made

14 available under this section unless an application or

15 proposal for such funding has been approved by the

16 Secretary in accordance with applicable regulations

17 and has forth reasonable assurance by the applicant

18 that, at all times after the construction, expansion,

19 or modernization of a facility carried out pursuant

20 to funding received under this section—

21 ‘‘(A) adequate financial support will be

22 available for the provision of services at such

23 facility;
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1 ‘‘(B) such facility will be available to eligi2 ble Indians without regard to ability to pay or

3 source of payment; and

4 ‘‘(C) such facility will, as feasible without

5 diminishing the quality or quantity of services

6 provided to eligible Indians, serve noneligible

7 persons on a cost basis.

8 ‘‘(2) PRIORITY.—In awarding funding under

9 this section, the Secretary shall give priority to In10 dian Tribes and Tribal Organizations that

11 demonstrate—

12 ‘‘(A) a need for increased ambulatory care

13 services; and

14 ‘‘(B) insufficient capacity to deliver such

15 services.

16 ‘‘(3) PEER REVIEW PANELS.—The Secretary

17 may provide for the establishment of peer review

18 panels, as necessary, to review and evaluate applica19 tions and proposals and to advise the Secretary re20 garding such applications using the criteria devel21 oped during consultations pursuant to subsection

22 (a)(1).

23 ‘‘(d) REVERSION OF FACILITIES.—If any facility (or

24 portion thereof) with respect to which funds have been

25 paid under this section, ceases, within 5 years after com-
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1 pletion of the construction, expansion, or modernization

2 carried out with such funds, to be used for the purposes

3 of providing health care services to eligible Indians, all of

4 the right, title, and interest in and to such facility (or por5 tion thereof) shall transfer to the United States unless

6 otherwise negotiated by the Service and the Indian Tribe

7 or Tribal Organization.

8 ‘‘(e) FUNDING NONRECURRING.—Funding provided

9 under this section shall be nonrecurring and shall not be

10 available for inclusion in any individual Indian Tribe’s

11 tribal share for an award under the Indian Self-Deter12 mination and Education Assistance Act or for reallocation

13 or redesign thereunder.

14 ‘‘SEC. 306. INDIAN HEALTH CARE DELIVERY DEMONSTRA15 TION PROJECT.

16 ‘‘(a) HEALTH CARE DEMONSTRATION PROJECTS.—

17 The Secretary, acting through the Service, and in con18 sultation with Indian Tribes and Tribal Organizations, is

19 authorized to enter into construction agreements under

20 the Indian Self-Determination and Education Assistance

21 Act (25 U.S.C. 450 et seq.) with Indian Tribes or Tribal

22 Organizations for the purpose of carrying out a health

23 care delivery demonstration project to test alternative

24 means of delivering health care and services to Indians

25 through facilities.
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1 ‘‘(b) USE OF FUNDS.—The Secretary, in approving

2 projects pursuant to this section, may authorize funding

3 for the construction and renovation of hospitals, health

4 centers, health stations, and other facilities to deliver

5 health care services and is authorized to—

6 ‘‘(1) waive any leasing prohibition;

7 ‘‘(2) permit carryover of funds appropriated for

8 the provision of health care services;

9 ‘‘(3) permit the use of other available funds;

10 ‘‘(4) permit the use of funds or property do11 nated from any source for project purposes;

12 ‘‘(5) provide for the reversion of donated real or

13 personal property to the donor; and

14 ‘‘(6) permit the use of Service funds to match

15 other funds, including Federal funds.

16 ‘‘(c) REGULATIONS.—The Secretary shall develop

17 and promulgate regulations not later than 1 year after the

18 date of enactment of the Indian Health Care Improvement

19 Act Amendments of 2005. If the Secretary has not pro20 mulgated regulations by that date, the Secretary shall de21 velop and publish regulations, through rulemaking under

22 section 802, for the review and approval of applications

23 submitted under this section.

24 ‘‘(d) CRITERIA.—The Secretary may approve projects

25 that meet the following criteria:
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1 ‘‘(1) There is a need for a new facility or pro2 gram or the reorientation of an existing facility or

3 program.

4 ‘‘(2) A significant number of Indians, including

5 those with low health status, will be served by the

6 project.

7 ‘‘(3) The project has the potential to deliver

8 services in an efficient and effective manner.

9 ‘‘(4) The project is economically viable.

10 ‘‘(5) The Indian Tribe or Tribal Organization

11 has the administrative and financial capability to ad12 minister the project.

13 ‘‘(6) The project is integrated with providers of

14 related health and social services and is coordinated

15 with, and avoids duplication of, existing services.

16 ‘‘(e) PEER REVIEW PANELS.—The Secretary may

17 provide for the establishment of peer review panels, as nec18 essary, to review and evaluate applications using the cri19 teria developed pursuant to subsection (d).

20 ‘‘(f) PRIORITY.—The Secretary shall give priority to

21 applications for demonstration projects in each of the fol22 lowing Service Units to the extent that such applications

23 are timely filed and meet the criteria specified in sub24 section (d):

25 ‘‘(1) Cass Lake, Minnesota.
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1 ‘‘(2) Clinton, Oklahoma.

2 ‘‘(3) Harlem, Montana.

3 ‘‘(4) Mescalero, New Mexico.

4 ‘‘(5) Owyhee, Nevada.

5 ‘‘(6) Parker, Arizona.

6 ‘‘(7) Schurz, Nevada.

7 ‘‘(8) Winnebago, Nebraska.

8 ‘‘(9) Ft. Yuma, California.

9 ‘‘(g) TECHNICAL ASSISTANCE.—The Secretary shall

10 provide such technical and other assistance as may be nec11 essary to enable applicants to comply with the provisions

12 of this section.

13 ‘‘(h) SERVICE TO INELIGIBLE PERSONS.—Subject to

14 section 807, the authority to provide services to persons

15 otherwise ineligible for the health care benefits of the

16 Service and the authority to extend hospital privileges in

17 Service facilities to non-Service health practitioners as

18 provided in section 807 may be included, subject to the

19 terms of such section, in any demonstration project ap20 proved pursuant to this section.

21 ‘‘(i) EQUITABLE TREATMENT.—For purposes of sub22 section (d)(1), the Secretary shall, in evaluating facilities

23 operated under any contract or compact under the Indian

24 Self-Determination and Education Assistance Act (25

25 U.S.C. 450 et seq.), use the same criteria that the Sec-
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1 retary uses in evaluating facilities operated directly by the

2 Service.

3 ‘‘(j) EQUITABLE INTEGRATION OF FACILITIES.—The

4 Secretary shall ensure that the planning, design, construc5 tion, renovation, and expansion needs of Service and non6 Service facilities which are the subject of a contract or

7 compact under the Indian Self-Determination and Edu8 cation Assistance Act (25 U.S.C. 450 et seq.) for health

9 services are fully and equitably integrated into the imple10 mentation of the health care delivery demonstration

11 projects under this section.

12 ‘‘SEC. 307. LAND TRANSFER.

13 ‘‘Notwithstanding any other provision of law, the Bu14 reau of Indian Affairs and all other agencies and depart15 ments of the United States are authorized to transfer, at

16 no cost, land and improvements to the Service for the pro17 vision of health care services. The Secretary is authorized

18 to accept such land and improvements for such purposes.

19 ‘‘SEC. 308. LEASES, CONTRACTS, AND OTHER AGREEMENTS.

20 ‘‘The Secretary, acting through the Service, may

21 enter into leases, contracts, and other agreements with In22 dian Tribes and Tribal Organizations which hold (1) title

23 to, (2) a leasehold interest in, or (3) a beneficial interest

24 in (when title is held by the United States in trust for

25 the benefit of an Indian Tribe) facilities used or to be used
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1 for the administration and delivery of health services by

2 an Indian Health Program. Such leases, contracts, or

3 agreements may include provisions for construction or ren4 ovation and provide for compensation to the Indian Tribe

5 or Tribal Organization of rental and other costs consistent

6 with section 105(l) of the Indian Self-Determination and

7 Education Assistance Act and regulations thereunder.

8 ‘‘SEC. 309. STUDY ON LOANS, LOAN GUARANTEES, AND

9 LOAN REPAYMENT.

10 ‘‘(a) IN GENERAL.—The Secretary, in consultation

11 with the Secretary of the Treasury, Indian Tribes, and

12 Tribal Organizations, shall carry out a study to determine

13 the feasibility of establishing a loan fund to provide to In14 dian Tribes and Tribal Organizations direct loans or guar15 antees for loans for the construction of health care facili16 ties, including—

17 ‘‘(1) inpatient facilities;

18 ‘‘(2) outpatient facilities;

19 ‘‘(3) staff quarters;

20 ‘‘(4) hostels; and

21 ‘‘(5) specialized care facilities, such as behav22 ioral health and elder care facilities.

23 ‘‘(b) DETERMINATIONS.—In carrying out the study

24 under subsection (a), the Secretary shall determine—
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1 ‘‘(1) the maximum principal amount of a loan

2 or loan guarantee that should be offered to a recipi3 ent from the loan fund;

4 ‘‘(2) the percentage of eligible costs, not to ex5 ceed 100 percent, that may be covered by a loan or

6 loan guarantee from the loan fund (including costs

7 relating to planning, design, financing, site land de8 velopment, construction, rehabilitation, renovation,

9 conversion, improvements, medical equipment and

10 furnishings, and other facility-related costs and cap11 ital purchase (but excluding staffing));

12 ‘‘(3) the cumulative total of the principal of di13 rect loans and loan guarantees, respectively, that

14 may be outstanding at any 1 time;

15 ‘‘(4) the maximum term of a loan or loan guar16 antee that may be made for a facility from the loan

17 fund;

18 ‘‘(5) the maximum percentage of funds from

19 the loan fund that should be allocated for payment

20 of costs associated with planning and applying for a

21 loan or loan guarantee;

22 ‘‘(6) whether acceptance by the Secretary of an

23 assignment of the revenue of an Indian Tribe or

24 Tribal Organization as security for any direct loan
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1 or loan guarantee from the loan fund would be ap2 propriate;

3 ‘‘(7) whether, in the planning and design of

4 health facilities under this section, users eligible

5 under section 807(c) may be included in any projec6 tion of patient population;

7 ‘‘(8) whether funds of the Service provided

8 through loans or loan guarantees from the loan fund

9 should be eligible for use in matching other Federal

10 funds under other programs;

11 ‘‘(9) the appropriateness of, and best methods

12 for, coordinating the loan fund with the health care

13 priority system of the Service under section 301; and

14 ‘‘(10) any legislative or regulatory changes re15 quired to implement recommendations of the Sec16 retary based on results of the study.

17 ‘‘(c) REPORT.—Not later than September 30, 2007,

18 the Secretary shall submit to the Committee on Indian Af19 fairs of the Senate and the Committee on Resources and

20 the Committee on Energy and Commerce of the House

21 of Representatives a report that describes—

22 ‘‘(1) the manner of consultation made as re23 quired by subsection (a); and
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1 ‘‘(2) the results of the study, including any rec2 ommendations of the Secretary based on results of

3 the study.

4 ‘‘SEC. 310. TRIBAL LEASING.

5 ‘‘A Tribal Health Program may lease permanent

6 structures for the purpose of providing health care services

7 without obtaining advance approval in appropriation Acts.

8 ‘‘SEC. 311. INDIAN HEALTH SERVICE/TRIBAL FACILITIES

9 JOINT VENTURE PROGRAM.

10 ‘‘(a) IN GENERAL.—The Secretary, acting through

11 the Service, shall make arrangements with Indian Tribes

12 and Tribal Organizations to establish joint venture dem13 onstration projects under which an Indian Tribe or Tribal

14 Organization shall expend tribal, private, or other avail15 able funds, for the acquisition or construction of a health

16 facility for a minimum of 10 years, under a no-cost lease,

17 in exchange for agreement by the Service to provide the

18 equipment, supplies, and staffing for the operation and

19 maintenance of such a health facility. An Indian Tribe or

20 Tribal Organization may use tribal funds, private sector,

21 or other available resources, including loan guarantees, to

22 fulfill its commitment under a joint venture entered into

23 under this subsection. An Indian Tribe or Tribal Organi24 zation shall be eligible to establish a joint venture project

25 if, when it submits a letter of intent, it—
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1 ‘‘(1) has begun but not completed the process

2 of acquisition or construction of a health facility to

3 be used in the joint venture project; or

4 ‘‘(2) has not begun the process of acquisition or

5 construction of a health facility for use in the joint

6 venture project.

7 ‘‘(b) REQUIREMENTS.—The Secretary shall make

8 such an arrangement with an Indian Tribe or Tribal Orga9 nization only if—

10 ‘‘(1) the Secretary first determines that the In11 dian Tribe or Tribal Organization has the adminis12 trative and financial capabilities necessary to com13 plete the timely acquisition or construction of the

14 relevant health facility; and

15 ‘‘(2) the Indian Tribe or Tribal Organization

16 meets the need criteria which shall be developed

17 through the negotiated rulemaking process provided

18 for under section 802.

19 ‘‘(c) CONTINUED OPERATION.—The Secretary shall

20 negotiate an agreement with the Indian Tribe or Tribal

21 Organization regarding the continued operation of the fa22 cility at the end of the initial 10 year no-cost lease period.

23 ‘‘(d) BREACH OF AGREEMENT.—An Indian Tribe or

24 Tribal Organization that has entered into a written agree25 ment with the Secretary under this section, and that
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1 breaches or terminates without cause such agreement,

2 shall be liable to the United States for the amount that

3 has been paid to the Indian Tribe or Tribal Organization,

4 or paid to a third party on the Indian Tribe’s or Tribal

5 Organization’s behalf, under the agreement. The Sec6 retary has the right to recover tangible property (including

7 supplies) and equipment, less depreciation, and any funds

8 expended for operations and maintenance under this sec9 tion. The preceding sentence does not apply to any funds

10 expended for the delivery of health care services, person11 nel, or staffing.

12 ‘‘(e) RECOVERY FOR NONUSE.—An Indian Tribe or

13 Tribal Organization that has entered into a written agree14 ment with the Secretary under this subsection shall be en15 titled to recover from the United States an amount that

16 is proportional to the value of such facility if, at any time

17 within the 10-year term of the agreement, the Service

18 ceases to use the facility or otherwise breaches the agree19 ment.

20 ‘‘(f) DEFINITION.—For the purposes of this section,

21 the term ‘health facility’ or ‘health facilities’ includes

22 quarters needed to provide housing for staff of the rel23 evant Tribal Health Program.
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1 ‘‘SEC. 312. LOCATION OF FACILITIES.

2 ‘‘(a) IN GENERAL.—In all matters involving the reor3 ganization or development of Service facilities or in the

4 establishment of related employment projects to address

5 unemployment conditions in economically depressed areas,

6 the Bureau of Indian Affairs and the Service shall give

7 priority to locating such facilities and projects on Indian

8 lands, or lands in Alaska owned by any Alaska Native vil9 lage, or village or regional corporation under the Alaska

10 Native Claims Settlement Act, or any land allotted to any

11 Alaska Native, if requested by the Indian owner and the

12 Indian Tribe with jurisdiction over such lands or other

13 lands owned or leased by the Indian Tribe or Tribal Orga14 nization. Top priority shall be given to Indian land owned

15 by 1 or more Indian Tribes.

16 ‘‘(b) DEFINITION.—For purposes of this section, the

17 term ‘Indian lands’ means—

18 ‘‘(1) all lands within the exterior boundaries of

19 any reservation; and

20 ‘‘(2) any lands title to which is held in trust by

21 the United States for the benefit of any Indian

22 Tribe or individual Indian or held by any Indian

23 Tribe or individual Indian subject to restriction by

24 the United States against alienation.
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1 ‘‘SEC. 313. MAINTENANCE AND IMPROVEMENT OF HEALTH

2 CARE FACILITIES.

3 ‘‘(a) REPORT.—The Secretary shall submit to the

4 President, for inclusion in the report required to be trans5 mitted to Congress under section 801, a report which iden6 tifies the backlog of maintenance and repair work required

7 at both Service and tribal health care facilities, including

8 new health care facilities expected to be in operation in

9 the next fiscal year. The report shall also identify the need

10 for renovation and expansion of existing facilities to sup11 port the growth of health care programs.

12 ‘‘(b) MAINTENANCE OF NEWLY CONSTRUCTED

13 SPACE.—The Secretary, acting through the Service, is au14 thorized to expend maintenance and improvement funds

15 to support maintenance of newly constructed space only

16 if such space falls within the approved supportable space

17 allocation for the Indian Tribe or Tribal Organization.

18 Supportable space allocation shall be defined through the

19 negotiated rulemaking process provided for under section

20 802.

21 ‘‘(c) REPLACEMENT FACILITIES.—In addition to

22 using maintenance and improvement funds for renovation,

23 modernization, and expansion of facilities, an Indian Tribe

24 or Tribal Organization may use maintenance and improve25 ment funds for construction of a replacement facility if

26 the costs of renovation of such facility would exceed a
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1 maximum renovation cost threshold. The maximum ren2 ovation cost threshold shall be determined through the ne3 gotiated rulemaking process provided for under section

4 802.

5 ‘‘SEC. 314. TRIBAL MANAGEMENT OF FEDERALLY OWNED

6 QUARTERS.

7 ‘‘(a) RENTAL RATES.—

8 ‘‘(1) ESTABLISHMENT.—Notwithstanding any

9 other provision of law, a Tribal Health Program

10 which operates a hospital or other health facility and

11 the federally owned quarters associated therewith

12 pursuant to a contract or compact under the Indian

13 Self-Determination and Education Assistance Act

14 (25 U.S.C. 450 et seq.) shall have the authority to

15 establish the rental rates charged to the occupants

16 of such quarters by providing notice to the Secretary

17 of its election to exercise such authority.

18 ‘‘(2) OBJECTIVES.—In establishing rental rates

19 pursuant to authority of this subsection, a Tribal

20 Health Program shall endeavor to achieve the follow21 ing objectives:

22 ‘‘(A) To base such rental rates on the rea23 sonable value of the quarters to the occupants

24 thereof.
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1 ‘‘(B) To generate sufficient funds to pru2 dently provide for the operation and mainte3 nance of the quarters, and subject to the discre4 tion of the Tribal Health Program, to supply

5 reserve funds for capital repairs and replace6 ment of the quarters.

7 ‘‘(3) EQUITABLE FUNDING.—Any quarters

8 whose rental rates are established by a Tribal

9 Health Program pursuant to this subsection shall

10 remain eligible for quarters improvement and repair

11 funds to the same extent as all federally owned

12 quarters used to house personnel in Services-sup13 ported programs.

14 ‘‘(4) NOTICE OF RATE CHANGE.—A Tribal

15 Health Program which exercises the authority pro16 vided under this subsection shall provide occupants

17 with no less than 60 days notice of any change in

18 rental rates.

19 ‘‘(b) DIRECT COLLECTION OF RENT.—

20 ‘‘(1) IN GENERAL.—Notwithstanding any other

21 provision of law, and subject to paragraph (2), a

22 Tribal Health Program shall have the authority to

23 collect rents directly from Federal employees who oc24 cupy such quarters in accordance with the following:
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1 ‘‘(A) The Tribal Health Program shall no2 tify the Secretary and the subject Federal em3 ployees of its election to exercise its authority

4 to collect rents directly from such Federal em5 ployees.

6 ‘‘(B) Upon receipt of a notice described in

7 subparagraph (A), the Federal employees shall

8 pay rents for occupancy of such quarters di9 rectly to the Tribal Health Program and the

10 Secretary shall have no further authority to col11 lect rents from such employees through payroll

12 deduction or otherwise.

13 ‘‘(C) Such rent payments shall be retained

14 by the Tribal Health Program and shall not be

15 made payable to or otherwise be deposited with

16 the United States.

17 ‘‘(D) Such rent payments shall be depos18 ited into a separate account which shall be used

19 by the Tribal Health Program for the mainte20 nance (including capital repairs and replace21 ment) and operation of the quarters and facili22 ties as the Tribal Health Program shall deter23 mine.

24 ‘‘(2) RETROCESSION OF AUTHORITY.—If a

25 Tribal Health Program which has made an election
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1 under paragraph (1) requests retrocession of its au2 thority to directly collect rents from Federal employ3 ees occupying federally owned quarters, such ret4 rocession shall become effective on the earlier of—

5 ‘‘(A) the first day of the month that begins

6 no less than 180 days after the Tribal Health

7 Program notifies the Secretary of its desire to

8 retrocede; or

9 ‘‘(B) such other date as may be mutually

10 agreed by the Secretary and the Tribal Health

11 Program.

12 ‘‘(c) RATES IN ALASKA.—To the extent that a Tribal

13 Health Program, pursuant to authority granted in sub14 section (a), establishes rental rates for federally owned

15 quarters provided to a Federal employee in Alaska, such

16 rents may be based on the cost of comparable private rent17 al housing in the nearest established community with a

18 year-round population of 1,500 or more individuals.

19 ‘‘SEC. 315. APPLICABILITY OF BUY AMERICAN ACT RE20 QUIREMENT.

21 ‘‘(a) APPLICABILITY.—The Secretary shall ensure

22 that the requirements of the Buy American Act apply to

23 all procurements made with funds provided pursuant to

24 section 317. Indian Tribes and Tribal Organizations shall

25 be exempt from these requirements.
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1 ‘‘(b) EFFECT OF VIOLATION.—If it has been finally

2 determined by a court or Federal agency that any person

3 intentionally affixed a label bearing a ‘Made in America’

4 inscription or any inscription with the same meaning, to

5 any product sold in or shipped to the United States that

6 is not made in the United States, such person shall be

7 ineligible to receive any contract or subcontract made with

8 funds provided pursuant to section 317, pursuant to the

9 debarment, suspension, and ineligibility procedures de10 scribed in sections 9.400 through 9.409 of title 48, Code

11 of Federal Regulations.

12 ‘‘(c) DEFINITIONS.—For purposes of this section, the

13 term ‘Buy American Act’ means title III of the Act enti14 tled ‘An Act making appropriations for the Treasury and

15 Post Office Departments for the fiscal year ending June

16 30, 1934, and for other purposes’, approved March 3,

17 1933 (41 U.S.C. 10a et seq.).

18 ‘‘SEC. 316. OTHER FUNDING FOR FACILITIES.

19 ‘‘(a) AUTHORITY TO ACCEPT FUNDS.—The Sec20 retary is authorized to accept from any source, including

21 Federal and State agencies, funds that are available for

22 the construction of health care facilities and use such

23 funds to plan, design, and construct health care facilities

24 for Indians and to place such funds into a contract or com25 pact under the Indian Self-Determination and Education
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1 Assistance Act (25 U.S.C. 450 et seq.). Receipt of such

2 funds shall have no effect on the priorities established pur3 suant to section 301.

4 ‘‘(b) INTERAGENCY AGREEMENTS.—The Secretary is

5 authorized to enter into interagency agreements with

6 other Federal agencies or State agencies and other entities

7 and to accept funds from such Federal or State agencies

8 or other sources to provide for the planning, design, and

9 construction of health care facilities to be administered by

10 Indian Health Programs in order to carry out the pur11 poses of this Act and the purposes for which the funds

12 were appropriated or for which the funds were otherwise

13 provided.

14 ‘‘(c) TRANSFERRED FUNDS.—Any Federal agency to

15 which funds for the construction of health care facilities

16 are appropriated is authorized to transfer such funds to

17 the Secretary for the construction of health care facilities

18 to carry out the purposes of this Act as well as the pur19 poses for which such funds are appropriated to such other

20 Federal agency.

21 ‘‘(d) ESTABLISHMENT OF STANDARDS.—The Sec22 retary, through the Service, shall establish standards by

23 regulation, developed by rulemaking under section 802, for

24 the planning, design, and construction of health care fa25 cilities serving Indians under this Act.
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1 ‘‘SEC. 317. AUTHORIZATION OF APPROPRIATIONS.

2 ‘‘There are authorized to be appropriated such sums

3 as may be necessary for each fiscal year through fiscal

4 year 2015 to carry out this title.

5 ‘‘TITLE IV—ACCESS TO HEALTH

6 SERVICES

7 ‘‘SEC. 401. TREATMENT OF PAYMENTS UNDER SOCIAL SE8 CURITY ACT HEALTH CARE PROGRAMS.

9 ‘‘(a) DISREGARD OF MEDICARE, MEDICAID, AND

10 SCHIP PAYMENTS IN DETERMINING APPROPRIATIONS.—

11 Any payments received by an Indian Health Program or

12 by an Urban Indian Organization made under title XVIII,

13 XIX, or XXI of the Social Security Act for services pro14 vided to Indians eligible for benefits under such respective

15 titles shall not be considered in determining appropria16 tions for the provision of health care and services to Indi17 ans.

18 ‘‘(b) NONPREFERENTIAL TREATMENT.—Nothing in

19 this Act authorizes the Secretary to provide services to an

20 Indian with coverage under title XVIII, XIX, or XXI of

21 the Social Security Act in preference to an Indian without

22 such coverage.

23 ‘‘(c) USE OF FUNDS.—

24 ‘‘(1) SPECIAL FUND.—Notwithstanding any

25 other provision of law, but subject to paragraph (2),

26 payments to which a facility of the Service is enti-
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1 tled by reason of a provision of the Social Security

2 Act shall be placed in a special fund to be held by

3 the Secretary and first used (to such extent or in

4 such amounts as are provided in appropriation Acts)

5 for the purpose of making any improvements in the

6 programs of the Service which may be necessary to

7 achieve or maintain compliance with the applicable

8 conditions and requirements of titles XVIII, XIX,

9 and XXI of the Social Security Act. Any amounts to

10 be reimbursed that are in excess of the amount nec11 essary to achieve or maintain such conditions and

12 requirements shall, subject to the consultation with

13 Indian Tribes being served by the Service Unit, be

14 used for reducing the health resource deficiencies of

15 the Indian Tribes. In making payments from such

16 fund, the Secretary shall ensure that each Service

17 Unit of the Service receives 100 percent of the

18 amount to which the facilities of the Service, for

19 which such Service Unit makes collections, are enti20 tled by reason of a provision of the Social Security

21 Act.

22 ‘‘(2) DIRECT PAYMENT OPTION.—Paragraph

23 (1) shall not apply upon the election of a Tribal

24 Health Program under subsection (d) to receive pay25 ments directly. No payment may be made out of the
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1 special fund described in such paragraph with re2 spect to reimbursement made for services provided

3 during the period of such election.

4 ‘‘(d) DIRECT BILLING.—

5 ‘‘(1) IN GENERAL.—A Tribal Health Program

6 may directly bill for, and receive payment for, health

7 care items and services provided by such Indian

8 Tribe or Tribal organization for which payment is

9 made under title XVIII, XIX, or XXI of the Social

10 Security Act or from any other third party payor.

11 ‘‘(2) DIRECT REIMBURSEMENT.—

12 ‘‘(A) USE OF FUNDS.—Each Tribal Health

13 Program exercising the option described in

14 paragraph (1) with respect to a program under

15 a title of the Social Security Act shall be reim16 bursed directly by that program for items and

17 services furnished without regard to section

18 401(c), but all amounts so reimbursed shall be

19 used by the Tribal Health Program for the pur20 pose of making any improvements in Tribal fa21 cilities or Tribal Health Programs that may be

22 necessary to achieve or maintain compliance

23 with the conditions and requirements applicable

24 generally to such items and services under the

25 program under such title and to provide addi-
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1 tional health care services, improvements in

2 health care facilities and Tribal Health Pro3 grams, any health care-related purpose, or oth4 erwise to achieve the objectives provided in sec5 tion 3 of this Act.

6 ‘‘(B) AUDITS.—The amounts paid to an

7 Indian Tribe or Tribal Organization exercising

8 the option described in paragraph (1) with re9 spect to a program under a title of the Social

10 Security Act shall be subject to all auditing re11 quirements applicable to programs administered

12 by an Indian Health Program.

13 ‘‘(C) IDENTIFICATION OF SOURCE OF PAY14 MENTS.—If an Indian Tribe or Tribal Organi15 zation receives funding from the Service under

16 the Indian Self-Determination and Education

17 Assistance Act or an Urban Indian Organiza18 tion receives funding from the Service under

19 title V of this Act and receives reimbursements

20 or payments under title XVIII, XIX, or XXI of

21 the Social Security Act, such Indian Tribe or

22 Tribal Organization, or Urban Indian Organiza23 tion, shall provide to the Service a list of each

24 provider enrollment number (or other identifier)
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1 under which it receives such reimbursements or

2 payments.

3 ‘‘(3) EXAMINATION AND IMPLEMENTATION OF

4 CHANGES.—The Secretary, acting through the Serv5 ice and with the assistance of the Administrator of

6 the Centers for Medicare & Medicaid Services, shall

7 examine on an ongoing basis and implement any ad8 ministrative changes that may be necessary to facili9 tate direct billing and reimbursement under the pro10 gram established under this subsection, including

11 any agreements with States that may be necessary

12 to provide for direct billing under a program under

13 a title of the Social Security Act.

14 ‘‘(4) WITHDRAWAL FROM PROGRAM.—A Tribal

15 Health Program that bills directly under the pro16 gram established under this subsection may with17 draw from participation in the same manner and

18 under the same conditions that an Indian Tribe or

19 Tribal Organization may retrocede a contracted pro20 gram to the Secretary under the authority of the In21 dian Self-Determination and Education Assistance

22 Act (25 U.S.C. 450 et seq.). All cost accounting and

23 billing authority under the program established

24 under this subsection shall be returned to the Sec-
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1 retary upon the Secretary’s acceptance of the with2 drawal of participation in this program.

3 ‘‘SEC. 402. GRANTS TO AND CONTRACTS WITH THE SERV4 ICE, INDIAN TRIBES, TRIBAL ORGANIZA5 TIONS, AND URBAN INDIAN ORGANIZATIONS.

6 ‘‘(a) INDIAN TRIBES AND TRIBAL ORGANIZA7 TIONS.—The Secretary, acting through the Service, shall

8 make grants to or enter into contracts with Indian Tribes

9 and Tribal Organizations to assist such Tribes and Tribal

10 Organizations in establishing and administering programs

11 on or near reservations and trust lands to assist individual

12 Indians—

13 ‘‘(1) to enroll for benefits under title XVIII,

14 XIX, or XXI of the Social Security Act and other

15 health benefits programs; and

16 ‘‘(2) to pay premiums for coverage for such

17 benefits, which may be based on financial need (as

18 determined by the Indian Tribe or Tribes being

19 served based on a schedule of income levels devel20 oped or implemented by such Tribe or Tribes).

21 ‘‘(b) CONDITIONS.—The Secretary, acting through

22 the Service, shall place conditions as deemed necessary to

23 effect the purpose of this section in any grant or contract

24 which the Secretary makes with any Indian Tribe or Trib25 al Organization pursuant to this section. Such conditions
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1 shall include requirements that the Indian Tribe or Tribal

2 Organization successfully undertake—

3 ‘‘(1) to determine the population of Indians eli4 gible for the benefits described in subsection (a);

5 ‘‘(2) to educate Indians with respect to the ben6 efits available under the respective programs;

7 ‘‘(3) to provide transportation for such individ8 ual Indians to the appropriate offices for enrollment

9 or applications for such benefits; and

10 ‘‘(4) to develop and implement methods of im11 proving the participation of Indians in receiving the

12 benefits provided under titles XVIII, XIX, and XXI

13 of the Social Security Act.

14 ‘‘(c) AGREEMENTS RELATING TO IMPROVING EN15 ROLLMENT OF INDIANS UNDER SOCIAL SECURITY ACT

16 PROGRAMS.—

17 ‘‘(1) AGREEMENTS WITH SECRETARY TO IM18 PROVE RECEIPT AND PROCESSING OF APPLICA19 TIONS.—

20 ‘‘(A) AUTHORIZATION.—The Secretary,

21 acting through the Service, may enter into an

22 agreement with an Indian Tribe, Tribal Organi23 zation, or Urban Indian Organization which

24 provides for the receipt and processing of appli25 cations by Indians for assistance under titles
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1 XIX and XXI of the Social Security Act, and

2 benefits under title XVIII of such Act, by an

3 Indian Health Program or Urban Indian Orga4 nization.

5 ‘‘(B) REIMBURSEMENT OF COSTS.—Such

6 agreements may provide for reimbursement of

7 costs of outreach, education regarding eligibility

8 and benefits, and translation when such services

9 are provided. The reimbursement may, as ap10 propriate, be added to the applicable rate per

11 encounter or be provided as a separate fee-for12 service payment to the Indian Tribe or Tribal

13 Organization.

14 ‘‘(C) PROCESSING CLARIFIED.—In this

15 paragraph, the term ‘processing’ does not in16 clude a final determination of eligibility.

17 ‘‘(2) AGREEMENTS WITH STATES FOR OUT18 REACH ON OR NEAR RESERVATION.—

19 ‘‘(A) IN GENERAL.—In order to improve

20 the access of Indians residing on or near a res21 ervation to obtain benefits under title XIX or

22 XXI of the Social Security Act, the Secretary

23 shall encourage the State to take steps to pro24 vide for enrollment on or near the reservation.

25 Such steps may include outreach efforts such as
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1 the outstationing of eligibility workers, entering

2 into agreements with Indian Tribes and Tribal

3 Organizations to provide outreach, education re4 garding eligibility and benefits, enrollment, and

5 translation services when such services are pro6 vided.

7 ‘‘(B) CONSTRUCTION.—Nothing in sub8 paragraph (A) shall be construed as affecting

9 arrangements entered into between States and

10 Indian Tribes and Tribal Organizations for

11 such Indian Tribes and Tribal Organizations to

12 conduct administrative activities under such ti13 tles.

14 ‘‘(d) FACILITATING COOPERATION.—The Secretary,

15 acting through the Centers for Medicare & Medicaid Serv16 ices, shall take such steps as are necessary to facilitate

17 cooperation with, and agreements between, States and the

18 Service, Indian Tribes, Tribal Organizations, or Urban In19 dian Organizations.

20 ‘‘(e) APPLICATION TO URBAN INDIAN ORGANIZA21 TIONS.—

22 ‘‘(1) IN GENERAL.—The provisions of sub23 section (a) shall apply with respect to grants and

24 other funding to Urban Indian Organizations with

25 respect to populations served by such organizations
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1 in the same manner they apply to grants and con2 tracts with Indian Tribes and Tribal Organizations

3 with respect to programs on or near reservations.

4 ‘‘(2) REQUIREMENTS.—The Secretary shall in5 clude in the grants or contracts made or provided

6 under paragraph (1) requirements that are—

7 ‘‘(A) consistent with the requirements im8 posed by the Secretary under subsection (b);

9 ‘‘(B) appropriate to Urban Indian Organi10 zations and Urban Indians; and

11 ‘‘(C) necessary to effect the purposes of

12 this section.

13 ‘‘SEC. 403. REIMBURSEMENT FROM CERTAIN THIRD PAR14 TIES OF COSTS OF HEALTH SERVICES.

15 ‘‘(a) RIGHT OF RECOVERY.—Except as provided in

16 subsection (f), the United States, an Indian Tribe, or

17 Tribal Organization shall have the right to recover from

18 an insurance company, health maintenance organization,

19 employee benefit plan, third-party tortfeasor, or any other

20 responsible or liable third party (including a political sub21 division or local governmental entity of a State) the rea22 sonable charges as determined by the Secretary, and billed

23 by the Secretary, an Indian Tribe, or Tribal Organization,

24 in providing health services, through the Service, an In25 dian Tribe, or Tribal Organization to any individual to the
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1 same extent that such individual, or any nongovernmental

2 provider of such services, would be eligible to receive dam3 ages, reimbursement, or indemnification for such charges

4 or expenses if—

5 ‘‘(1) such services had been provided by a non6 governmental provider; and

7 ‘‘(2) such individual had been required to pay

8 such charges or expenses and did pay such charges

9 or expenses.

10 ‘‘(b) LIMITATIONS ON RECOVERIES FROM STATES.—

11 Subsection (a) shall provide a right of recovery against

12 any State, only if the injury, illness, or disability for which

13 health services were provided is covered under—

14 ‘‘(1) workers’ compensation laws; or

15 ‘‘(2) a no-fault automobile accident insurance

16 plan or program.

17 ‘‘(c) NONAPPLICATION OF OTHER LAWS.—No law of

18 any State, or of any political subdivision of a State and

19 no provision of any contract, insurance or health mainte20 nance organization policy, employee benefit plan, self-in21 surance plan, managed care plan, or other health care plan

22 or program entered into or renewed after the date of the

23 enactment of the Indian Health Care Amendments of

24 1988, shall prevent or hinder the right of recovery of the
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1 United States, an Indian Tribe, or Tribal Organization

2 under subsection (a).

3 ‘‘(d) NO EFFECT ON PRIVATE RIGHTS OF ACTION.—

4 No action taken by the United States, an Indian Tribe,

5 or Tribal Organization to enforce the right of recovery

6 provided under this section shall operate to deny to the

7 injured person the recovery for that portion of the person’s

8 damage not covered hereunder.

9 ‘‘(e) ENFORCEMENT.—

10 ‘‘(1) IN GENERAL.—The United States, an In11 dian Tribe, or Tribal Organization may enforce the

12 right of recovery provided under subsection (a) by—

13 ‘‘(A) intervening or joining in any civil ac14 tion or proceeding brought—

15 ‘‘(i) by the individual for whom health

16 services were provided by the Secretary, an

17 Indian Tribe, or Tribal Organization; or

18 ‘‘(ii) by any representative or heirs of

19 such individual, or

20 ‘‘(B) instituting a civil action, including a

21 civil action for injunctive relief and other relief

22 and including, with respect to a political sub23 division or local governmental entity of a State,

24 such an action against an official thereof.
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1 ‘‘(2) NOTICE.—All reasonable efforts shall be

2 made to provide notice of action instituted under

3 paragraph (1)(B) to the individual to whom health

4 services were provided, either before or during the

5 pendency of such action.

6 ‘‘(f) LIMITATION.—Absent specific written authoriza7 tion by the governing body of an Indian Tribe for the pe8 riod of such authorization (which may not be for a period

9 of more than 1 year and which may be revoked at any

10 time upon written notice by the governing body to the

11 Service), the United States shall not have a right of recov12 ery under this section if the injury, illness, or disability

13 for which health services were provided is covered under

14 a self-insurance plan funded by an Indian Tribe, Tribal

15 Organization, or Urban Indian Organization. Where such

16 authorization is provided, the Service may receive and ex17 pend such amounts for the provision of additional health

18 services consistent with such authorization.

19 ‘‘(g) COSTS AND ATTORNEYS’ FEES.—In any action

20 brought to enforce the provisions of this section, a prevail21 ing plaintiff shall be awarded its reasonable attorneys’ fees

22 and costs of litigation.

23 ‘‘(h) NONAPPLICATION OF CLAIMS FILING REQUIRE24 MENTS.—An insurance company, health maintenance or25 ganization, self-insurance plan, managed care plan, or
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1 other health care plan or program (under the Social Secu2 rity Act or otherwise) may not deny a claim for benefits

3 submitted by the Service or by an Indian Tribe or Tribal

4 Organization based on the format in which the claim is

5 submitted if such format complies with the format re6 quired for submission of claims under title XVIII of the

7 Social Security Act or recognized under section 1175 of

8 such Act.

9 ‘‘(i) APPLICATION TO URBAN INDIAN ORGANIZA10 TIONS.—The previous provisions of this section shall apply

11 to Urban Indian Organizations with respect to populations

12 served by such Organizations in the same manner they

13 apply to Indian Tribes and Tribal Organizations with re14 spect to populations served by such Indian Tribes and

15 Tribal Organizations.

16 ‘‘(j) STATUTE OF LIMITATIONS.—The provisions of

17 section 2415 of title 28, United States Code, shall apply

18 to all actions commenced under this section, and the ref19 erences therein to the United States are deemed to include

20 Indian Tribes, Tribal Organizations, and Urban Indian

21 Organizations.

22 ‘‘(k) SAVINGS.—Nothing in this section shall be con23 strued to limit any right of recovery available to the

24 United States, an Indian Tribe, or Tribal Organization

25 under the provisions of any applicable, Federal, State, or
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1 Tribal law, including medical lien laws and the Federal

2 Medical Care Recovery Act (42 U.S.C. 2651 et seq.).

3 ‘‘SEC. 404. CREDITING OF REIMBURSEMENTS.

4 ‘‘(a) USE OF AMOUNTS.—

5 ‘‘(1) RETENTION BY PROGRAM.—Except as pro6 vided in section 202(g) (relating to the Catastrophic

7 Health Emergency Fund) and section 807 (relating

8 to health services for ineligible persons), all reim9 bursements received or recovered under any of the

10 programs described in paragraph (2), including

11 under section 807, by reason of the provision of

12 health services by the Service, by an Indian Tribe or

13 Tribal Organization, or by an Urban Indian Organi14 zation, shall be credited to the Service, such Indian

15 Tribe or Tribal Organization, or such Urban Indian

16 Organization, respectively, and may be used as pro17 vided in section 401. In the case of such a service

18 provided by or through a Service Unit, such

19 amounts shall be credited to such unit and used for

20 such purposes.

21 ‘‘(2) PROGRAMS COVERED.—The programs re22 ferred to in paragraph (1) are the following:

23 ‘‘(A) Titles XVIII, XIX, and XXI of the

24 Social Security Act.

25 ‘‘(B) This Act, including section 807.
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1 ‘‘(C) Public Law 87–693.

2 ‘‘(D) Any other provision of law.

3 ‘‘(b) NO OFFSET OF AMOUNTS.—The Service may

4 not offset or limit any amount obligated to any Service

5 Unit or entity receiving funding from the Service because

6 of the receipt of reimbursements under subsection (a).

7 ‘‘SEC. 405. PURCHASING HEALTH CARE COVERAGE.

8 ‘‘(a) IN GENERAL.—Insofar as amounts are made

9 available under law (including a provision of the Social

10 Security Act, the Indian Self-Determination and Edu11 cation Assistance Act, or other law, other than under sec12 tion 402) to Indian Tribes, Tribal Organizations, and

13 Urban Indian Organizations for health benefits for Service

14 beneficiaries, Indian Tribes, Tribal Organizations, and

15 Urban Indian Organizations may use such amounts to

16 purchase health benefits coverage for such beneficiaries in

17 any manner, including through—

18 ‘‘(1) a tribally owned and operated health care

19 plan;

20 ‘‘(2) a State or locally authorized or licensed

21 health care plan;

22 ‘‘(3) a health insurance provider or managed

23 care organization; or

24 ‘‘(4) a self-insured plan.
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1 The purchase of such coverage by an Indian Tribe, Tribal

2 Organization, or Urban Indian Organization may be based

3 on the financial needs of such beneficiaries (as determined

4 by the Indian Tribe or Tribes being served based on a

5 schedule of income levels developed or implemented by

6 such Indian Tribe or Tribes).

7 ‘‘(b) EXPENSES FOR SELF-INSURED PLAN.—In the

8 case of a self-insured plan under subsection (a)(4), the

9 amounts may be used for expenses of operating the plan,

10 including administration and insurance to limit the finan11 cial risks to the entity offering the plan.

12 ‘‘(c) CONSTRUCTION.—Nothing in this section shall

13 be construed as affecting the use of any amounts not re14 ferred to in subsection (a).

15 ‘‘SEC. 406. SHARING ARRANGEMENTS WITH FEDERAL AGEN16 CIES.

17 ‘‘(a) AUTHORITY.—

18 ‘‘(1) IN GENERAL.—The Secretary may enter

19 into (or expand) arrangements for the sharing of

20 medical facilities and services between the Service,

21 Indian Tribes, and Tribal Organizations and the De22 partment of Veterans Affairs and the Department of

23 Defense.

24 ‘‘(2) CONSULTATION BY SECRETARY RE25 QUIRED.—The Secretary may not finalize any ar-
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1 rangement between the Service and a Department

2 described in paragraph (1) without first consulting

3 with the Indian Tribes which will be significantly af4 fected by the arrangement.

5 ‘‘(b) LIMITATIONS.—The Secretary shall not take

6 any action under this section or under subchapter IV of

7 chapter 81 of title 38, United States Code, which would

8 impair—

9 ‘‘(1) the priority access of any Indian to health

10 care services provided through the Service and the

11 eligibility of any Indian to receive health services

12 through the Service;

13 ‘‘(2) the quality of health care services provided

14 to any Indian through the Service;

15 ‘‘(3) the priority access of any veteran to health

16 care services provided by the Department of Veter17 ans Affairs;

18 ‘‘(4) the quality of health care services provided

19 by the Department of Veterans Affairs or the De20 partment of Defense; or

21 ‘‘(5) the eligibility of any Indian who is a vet22 eran to receive health services through the Depart23 ment of Veterans Affairs.

24 ‘‘(c) REIMBURSEMENT.—The Service, Indian Tribe,

25 or Tribal Organization shall be reimbursed by the Depart-
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•S 1057 IS

1 ment of Veterans Affairs or the Department of Defense

2 (as the case may be) where services are provided through

3 the Service, an Indian Tribe, or a Tribal Organization to

4 beneficiaries eligible for services from either such Depart5 ment, notwithstanding any other provision of law.

6 ‘‘(d) CONSTRUCTION.—Nothing in this section may

7 be construed as creating any right of a non-Indian veteran

8 to obtain health services from the Service.

9 ‘‘SEC. 407. PAYOR OF LAST RESORT.

10 ‘‘Indian Health Programs and health care programs

11 operated by Urban Indian Organizations shall be the

12 payor of last resort for services provided to persons eligible

13 for services from Indian Health Programs and Urban In14 dian Organizations, notwithstanding any Federal, State,

15 or local law to the contrary.

16 ‘‘SEC. 408. NONDISCRIMINATION IN QUALIFICATIONS FOR

17 REIMBURSEMENT FOR SERVICES.

18 ‘‘For purposes of determining the eligibility of an en19 tity that is operated by the Service, an Indian Tribe, Trib20 al Organization, or Urban Indian Organization to receive

21 payment or reimbursement from any federally funded

22 health care program for health care services it furnishes

23 to an Indian. Such program must provide that such entity,

24 meeting generally applicable State or other requirements

25 applicable for participation, must be accepted as a pro-
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1 vider on the same basis as any other qualified provider,

2 except that any requirement that the entity be licensed

3 or recognized under State or local law to furnish such

4 services shall be deemed to have been met if the entity

5 meets all the applicable standards for such licensure, but

6 the entity need not obtain a license or other documenta7 tion. In determining whether the entity meets such stand8 ards, the absence of licensure of any staff member of the

9 entity may not be taken into account.

10 ‘‘SEC. 409. CONSULTATION.

11 ‘‘(a) TRIBAL TECHNICAL ADVISORY GROUP

12 (TTAG).—The Secretary shall maintain within the Cen13 ters for Medicaid & Medicare Services (CMS) a Tribal

14 Technical Advisory Group, established in accordance with

15 requirements of the charter dated September 30, 2003,

16 and in such group shall include a representative of the

17 Urban Indian Organizations and the Service. The rep18 resentative of the Urban Indian Organization shall be

19 deemed to be an elected officer of a tribal government for

20 purposes of applying section 204(b) of the Unfunded Man21 dates Reform Act of 1995 (2 U.S.C. 1534(b)).

22 ‘‘(b) SOLICITATION OF MEDICAID ADVICE.—

23 ‘‘(1) IN GENERAL.—As part of its plan under

24 title XIX of the Social Security Act, a State in

25 which the Service operates or funds health care pro-
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1 grams, or in which 1 or more Indian Health Pro2 grams or Urban Indian Organizations provide health

3 care in the State for which medical assistance is

4 available under such title, may establish a process

5 under which the State seeks advice on a regular, on6 going basis from designees of such Indian Health

7 Programs and Urban Indian Organizations on mat8 ters relating to the application of such title to and

9 likely to have a direct effect on such Indian Health

10 Programs and Urban Indian Organizations.

11 ‘‘(2) MANNER OF ADVICE.—The process de12 scribed in paragraph (1) should include solicitation

13 of advice prior to submission of any plan amend14 ments, waiver requests, and proposals for dem15 onstration projects likely to have a direct effect on

16 Indians, Indian Health Programs, or Urban Indian

17 Organizations. Such process may include appoint18 ment of an advisory committee and of a designee of

19 such Indian Health Programs and Urban Indian Or20 ganizations to the medical care advisory committee

21 advising the State on its medicaid plan.

22 ‘‘(3) PAYMENT OF EXPENSES.—The reasonable

23 expenses of carrying out this subsection shall be eli24 gible for reimbursement under section 1903(a) of

25 the Social Security Act.
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1 ‘‘(c) CONSTRUCTION.—Nothing in this section shall

2 be construed as superseding existing advisory committees,

3 working groups, or other advisory procedures established

4 by the Secretary or by any State.

5 ‘‘SEC. 410. STATE CHILDREN’S HEALTH INSURANCE PRO6 GRAM (SCHIP).

7 ‘‘(a) OPTIONAL USE OF FUNDS FOR INDIAN HEALTH

8 PROGRAM PAYMENTS.—Subject to the succeeding provi9 sions of this section, a State may provide under its State

10 child health plan under title XXI of the Social Security

11 Act (regardless of whether such plan is implemented under

12 such title, title XIX of such Act, or both) for payments

13 under this section to Indian Health Programs and Urban

14 Indian Organizations operating in the State. Such pay15 ments shall be treated under title XXI of the Social Secu16 rity Act as expenditures described in section

17 2105(a)(1)(A) of such Act.

18 ‘‘(b) USE OF FUNDS.—Payments under this section

19 may be used only for expenditures described in clauses (i)

20 through (iii) of section 2105(a)(1)(D) of the Social Secu21 rity Act for targeted low-income children or other low-in22 come children (as defined in 2110 of such Act) who are—

23 ‘‘(1) Indians; or

24 ‘‘(2) otherwise eligible for health services from

25 the Indian Health Program involved.
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1 ‘‘(c) SPECIAL RESTRICTIONS.—The following condi2 tions apply to a State electing to provide payments under

3 this section:

4 ‘‘(1) NO LIMITATION ON OTHER SCHIP PARTICI5 PATION OF, OR PROVIDER PAYMENTS TO, INDIAN

6 HEALTH PROGRAMS.—The State may not exclude or

7 limit participation of otherwise eligible Indian

8 Health Programs in its State child health program

9 under title XXI of the Social Security Act or its

10 medicaid program under title XIX of such Act or

11 pay such Programs less than they otherwise would

12 as participating providers on the basis that pay13 ments are made to such Programs under this sec14 tion.

15 ‘‘(2) NO LIMITATION ON OTHER SCHIP ELIGI16 BILITY OF INDIANS.—The State may not exclude or

17 limit participation of otherwise eligible Indian chil18 dren in such State child health or medicaid program

19 on the basis that payments are made for assistance

20 for such children under this section.

21 ‘‘(3) LIMITATION ON ACCEPTANCE OF CON22 TRIBUTIONS.—

23 ‘‘(A) IN GENERAL.—The State may not ac24 cept contributions or condition making of pay25 ments under this section upon contribution of
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1 funds from any Indian Health Program to meet

2 the State’s non-Federal matching fund require3 ments under titles XIX and XXI of the Social

4 Security Act.

5 ‘‘(B) CONTRIBUTION DEFINED.—For pur6 poses of subparagraph (A), the term ‘contribu7 tion’ includes any tax, donation, fee, or other

8 payment made, whether made voluntarily or in9 voluntarily.

10 ‘‘(d) APPLICATION OF SEPARATE 10 PERCENT LIMI11 TATION.—Payment may be made under section 2105(a)

12 of the Social Security Act to a State for a fiscal year for

13 payments under this section up to an amount equal to 10

14 percent of the total amount available under title XXI of

15 such Act (including allotments and reallotments available

16 from previous fiscal years) to the State with respect to

17 the fiscal year.

18 ‘‘(e) GENERAL TERMS.—A payment under this sec19 tion shall only be made upon application to the State from

20 the Indian Health Program involved and under such terms

21 and conditions, and in a form and manner, as the Sec22 retary determines appropriate.

23 ‘‘SEC. 411. SOCIAL SECURITY ACT SANCTIONS.

24 ‘‘(a) REQUESTS FOR WAIVER OF SANCTIONS.—
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1 ‘‘(1) IN GENERAL.—For purposes of applying

2 any authority under a provision of title XI, XVIII,

3 XIX, or XXI of the Social Security Act to seek a

4 waiver of a sanction imposed against a health care

5 provider insofar as that provider provides services to

6 individuals through an Indian Health Program, the

7 Indian Health Program shall request the State to

8 seek such waiver, and if such State has not sought

9 the waiver within 60 days of the Indian Health Pro10 gram request, the Indian Health Program itself may

11 petition the Secretary for such waiver.

12 ‘‘(2) PROCEDURE.—In seeking a waiver under

13 paragraph (1), the Indian Health Program must

14 provide notice and a copy of the request, including

15 the reasons for the waiver sought, to the State. The

16 Secretary may consider the State’s views in the de17 termination of the waiver request, but may not with18 hold or delay a determination based on the lack of

19 the State’s views.

20 ‘‘(b) SAFE HARBOR FOR TRANSACTIONS BETWEEN

21 AND AMONG INDIAN HEALTH CARE PROGRAMS.—For

22 purposes of applying section 1128B(b) of the Social Secu23 rity Act, the exchange of anything of value between or

24 among the following shall not be treated as remuneration
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1 if the exchange arises from or relates to any of the follow2 ing health programs:

3 ‘‘(1) An exchange between or among the follow4 ing:

5 ‘‘(A) Any Indian Health Program.

6 ‘‘(B) Any Urban Indian Organization.

7 ‘‘(2) An exchange between an Indian Tribe,

8 Tribal Organization, or an Urban Indian Organiza9 tion and any patient served or eligible for service

10 from an Indian Tribe, Tribal Organization, or

11 Urban Indian Organization, including patients

12 served or eligible for service pursuant to section 807,

13 but only if such exchange—

14 ‘‘(A) is for the purpose of transporting the

15 patient for the provision of health care items or

16 services;

17 ‘‘(B) is for the purpose of providing hous18 ing to the patient (including a pregnant pa19 tient) and immediate family members or an es20 cort incidental to assuring the timely provision

21 of health care items and services to the patient;

22 ‘‘(C) is for the purpose of paying pre23 miums, copayments, deductibles, or other cost24 sharing on behalf of patients; or
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1 ‘‘(D) consists of an item or service of small

2 value that is provided as a reasonable incentive

3 to secure timely and necessary preventive and

4 other items and services.

5 ‘‘(3) Other exchanges involving an Indian

6 Health Program, an Urban Indian Organization, or

7 an Indian Tribe or Tribal Organization that meet

8 such standards as the Secretary of Health and

9 Human Services, in consultation with the Attorney

10 General, determines is appropriate, taking into ac11 count the special circumstances of such Indian

12 Health Programs, Urban Indian Organizations, In13 dian Tribes, and Tribal Organizations and of pa14 tients served by Indian Health Programs, Urban In15 dian Organizations, Indian Tribes, and Tribal Orga16 nizations.

17 ‘‘SEC. 412. COST SHARING.

18 ‘‘(a) COINSURANCE, COPAYMENTS, AND

19 DEDUCTIBLES.—Notwithstanding any other provision of

20 Federal or State law—

21 ‘‘(1) PROTECTION FOR ELIGIBLE INDIANS

22 UNDER SOCIAL SECURITY ACT HEALTH PRO23 GRAMS.—No Indian who is furnished an item or

24 service for which payment may be made under title
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1 XIX or XXI of the Social Security Act may be

2 charged a deductible, copayment, or coinsurance.

3 ‘‘(2) PROTECTION FOR INDIANS.—No Indian

4 who is furnished an item or service by the Service

5 may be charged a deductible, copayment, or coinsur6 ance.

7 ‘‘(3) NO REDUCTION IN AMOUNT OF PAYMENT

8 TO INDIAN HEALTH PROVIDERS.—The payment or

9 reimbursement due to the Service, Indian Tribe,

10 Tribal Organization, or Urban Indian Organization

11 under title XIX or XXI of the Social Security Act

12 may not be reduced by the amount of the deductible,

13 copayment, or coinsurance that would be due from

14 the Indian but for the operation of this section.

15 ‘‘(b) EXEMPTION FROM MEDICAID AND SCHIP PRE16 MIUMS.—Notwithstanding any other provision of Federal

17 or State law, no Indian who is otherwise eligible for serv18 ices under title XIX of the Social Security Act (relating

19 to the medicaid program) or title XXI of such Act (relat20 ing to the State children’s health insurance program) may

21 be charged a premium, enrollment fee, or similar charge

22 as a condition of receiving benefits under the program

23 under the respective title.

24 ‘‘(c) TREATMENT OF CERTAIN PROPERTY FOR MED25 ICAID ELIGIBILITY.—Notwithstanding any other provision
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1 of Federal or State law, the following property may not

2 be included when determining eligibility for services under

3 title XIX of the Social Security Act:

4 ‘‘(1) Property, including real property and im5 provements, located on a reservation, including any

6 federally recognized Indian Tribe’s reservation,

7 Pueblo, or Colony, including former reservations in

8 Oklahoma, Alaska Native regions established by the

9 Alaska Native Claims Settlement Act and Indian al10 lotments on or near a reservation as designated and

11 approved by the Bureau of Indian Affairs of the De12 partment of the Interior.

13 ‘‘(2) For any federally recognized Tribe not de14 scribed in paragraph (1), property located within the

15 most recent boundaries of a prior Federal reserva16 tion.

17 ‘‘(3) Ownership interests in rents, leases, royal18 ties, or usage rights related to natural resources (in19 cluding extraction of natural resources or harvesting

20 of timber, other plants and plant products, animals,

21 fish, and shellfish) resulting from the exercise of fed22 erally protected rights.

23 ‘‘(4) Ownership interests in or usage rights to

24 items not covered by paragraphs (1) through (3)

25 that have unique religious, spiritual, traditional, or
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•S 1057 IS

1 cultural significance or rights that support subsist2 ence or a traditional life style according to applicable

3 tribal law or custom.

4 ‘‘(d) CONTINUATION OF CURRENT LAW PROTEC5 TIONS OF CERTAIN INDIAN PROPERTY FROM MEDICAID

6 ESTATE RECOVERY.—Income, resources, and property

7 that are exempt from medicaid estate recovery under title

8 XIX of the Social Security Act as of April 1, 2003, under

9 manual instructions issued to carry out section 1917(b)(3)

10 of such Act because of Federal responsibility for Indian

11 Tribes and Alaska Native Villages shall remain so exempt.

12 Nothing in this subsection shall be construed as prevent13 ing the Secretary from providing additional medicaid es14 tate recovery exemptions for Indians.

15 ‘‘SEC. 413. TREATMENT UNDER MEDICAID MANAGED CARE.

16 ‘‘(a) PROVISION OF SERVICES, TO ENROLLEES WITH

17 NON-INDIAN MEDICAID MANAGED CARE ENTITIES, BY

18 INDIAN HEALTH PROGRAMS AND URBAN INDIAN ORGANI19 ZATIONS.—

20 ‘‘(1) PAYMENT RULES.—

21 ‘‘(A) IN GENERAL.—Subject to subpara22 graph (B), in the case of an Indian who is en23 rolled with a non-Indian medicaid managed care

24 entity (as defined in subsection (c)) and who re25 ceives covered medicaid managed care services
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1 from an Indian Health Program or an Urban

2 Indian Organization, whether or not it is a par3 ticipating provider with respect to such entity,

4 the following rules apply:

5 ‘‘(i) DIRECT PAYMENT.—The entity

6 shall make prompt payment (in accordance

7 with rules applicable to medicaid managed

8 care entities under title XIX of the Social

9 Security Act) to the Indian Health Pro10 gram or Urban Indian Organization at a

11 rate established by the entity for such serv12 ices that is equal to the rate negotiated be13 tween such entity and the Program or Or14 ganization involved or, if such a rate has

15 not been negotiated, a rate that is not less

16 than the level and amount of payment

17 which the entity would make for the serv18 ices if the services were furnished by a pro19 vider which is not such a Program or Or20 ganization.

21 ‘‘(ii) PAYMENT THROUGH STATE.—If

22 there is no arrangement for direct payment

23 under clause (i) or if a State provides for

24 this clause to apply in lieu of clause (i),

25 the State shall provide for payment to the
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•S 1057 IS

1 Indian Health Program or Urban Indian

2 Organization under its State program

3 under title XIX of such Act at the rate

4 that would be otherwise applicable for such

5 services under such program and shall pro6 vide for an appropriate adjustment of the

7 capitation payment made to the entity to

8 take into account such payment.

9 ‘‘(B) COMPLIANCE WITH GENERALLY AP10 PLICABLE REQUIREMENTS.—

11 ‘‘(i) IN GENERAL.—Except as other12 wise provided, as a condition of payment

13 under subparagraph (A), the Indian

14 Health Program or Urban Indian Organi15 zation shall comply with the generally ap16 plicable requirements of title XIX of the

17 Social Security Act with respect to covered

18 services.

19 ‘‘(ii) SATISFACTION OF CLAIM RE20 QUIREMENT.—Any requirement for the

21 submission of a claim or other documenta22 tion for services covered under subpara23 graph (A) by the enrollee is deemed to be

24 satisfied through the submission of a claim

25 or other documentation by the Indian
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•S 1057 IS

1 Health Program or Urban Indian Organi2 zation consistent with section 403(h).

3 ‘‘(C) CONSTRUCTION.—Nothing in this

4 subsection shall be construed as waiving the ap5 plication of section 1902(a)(30)(A) of the Social

6 Security Act (relating to application of stand7 ards to assure that payments are consistent

8 with efficiency, economy, and quality of care).

9 ‘‘(2) ENROLLEE OPTION TO SELECT AN INDIAN

10 HEALTH PROGRAM OR URBAN INDIAN ORGANIZATION

11 AS PRIMARY CARE PROVIDER.—In the case of a non12 Indian medicaid managed care entity that—

13 ‘‘(A) has an Indian enrolled with the en14 tity; and

15 ‘‘(B) has an Indian Health Program or

16 Urban Indian Organization that is participating

17 as a primary care provider within the network

18 of the entity,

19 insofar as the Indian is otherwise eligible to receive

20 services from such Program or Organization and the

21 Program or Organization has the capacity to provide

22 primary care services to such Indian, the Indian

23 shall be allowed to choose such Program or Organi24 zation as the Indian’s primary care provider under

25 the entity.
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1 ‘‘(b) OFFERING OF MANAGED CARE THROUGH IN2 DIAN MEDICAID MANAGED CARE ENTITIES.—If—

3 ‘‘(1) a State elects to provide services through

4 medicaid managed care entities under its medicaid

5 managed care program; and

6 ‘‘(2) an Indian Health Program or Urban In7 dian Organization that is funded in whole or in part

8 by the Service, or a consortium thereof, has estab9 lished an Indian medicaid managed care entity in

10 the State that meets generally applicable standards

11 required of such an entity under such medicaid man12 aged care program,

13 the State shall offer to enter into an agreement with the

14 entity to serve as a medicaid managed care entity with

15 respect to eligible Indians served by such entity under

16 such program.

17 ‘‘(c) SPECIAL RULES FOR INDIAN MANAGED CARE

18 ENTITIES.—The following are special rules regarding the

19 application of a medicaid managed care program to Indian

20 medicaid managed care entities:

21 ‘‘(1) ENROLLMENT.—

22 ‘‘(A) LIMITATION TO INDIANS.—An Indian

23 medicaid managed care entity may restrict en24 rollment under such program to Indians and to

25 members of specific Tribes in the same manner
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•S 1057 IS

1 as Indian Health Programs may restrict the de2 livery of services to such Indians and tribal

3 members.

4 ‘‘(B) NO LESS CHOICE OF PLANS.—Under

5 such program the State may not limit the

6 choice of an Indian among medicaid managed

7 care entities only to Indian medicaid managed

8 care entities or to be more restrictive than the

9 choice of managed care entities offered to indi10 viduals who are not Indians.

11 ‘‘(C) DEFAULT ENROLLMENT.—

12 ‘‘(i) IN GENERAL.—If such program

13 of a State requires the enrollment of Indi14 ans in a medicaid managed care entity in

15 order to receive benefits, the State shall

16 provide for the enrollment of Indians de17 scribed in clause (ii) who are not otherwise

18 enrolled with such an entity in an Indian

19 medicaid managed care entity described in

20 such clause.

21 ‘‘(ii) INDIAN DESCRIBED.—An Indian

22 described in this clause, with respect to an

23 Indian medicaid managed care entity, is an

24 Indian who, based upon the service area

25 and capacity of the entity, is eligible to be
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1 enrolled with the entity consistent with

2 subparagraph (A).

3 ‘‘(D) EXCEPTION TO STATE LOCK-IN.—A

4 request by an Indian who is enrolled under such

5 program with a non-Indian medicaid managed

6 care entity to change enrollment with that en7 tity to enrollment with an Indian medicaid

8 managed care entity shall be considered cause

9 for granting such request under procedures

10 specified by the Secretary.

11 ‘‘(2) FLEXIBILITY IN APPLICATION OF SOL12 VENCY.—In applying section 1903(m)(1) of the So13 cial Security Act to an Indian medicaid managed

14 care entity—

15 ‘‘(A) any reference to a ‘State’ in subpara16 graph (A)(ii) of that section shall be deemed to

17 be a reference to the ‘Secretary’; and

18 ‘‘(B) the entity shall be deemed to be a

19 public entity described in subparagraph (C)(ii)

20 of that section.

21 ‘‘(3) EXCEPTIONS TO ADVANCE DIRECTIVES.—

22 The Secretary may modify or waive the require23 ments of section 1902(w) of the Social Security Act

24 (relating to provision of written materials on ad25 vance directives) insofar as the Secretary finds that
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•S 1057 IS

1 the requirements otherwise imposed are not an ap2 propriate or effective way of communicating the in3 formation to Indians.

4 ‘‘(4) FLEXIBILITY IN INFORMATION AND MAR5 KETING.—

6 ‘‘(A) MATERIALS.—The Secretary may

7 modify requirements under section 1932(a)(5)

8 of the Social Security Act in a manner that im9 proves the materials to take into account the

10 special circumstances of such entities and their

11 enrollees while maintaining and clearly commu12 nicating to potential enrollees their rights, pro13 tections, and benefits.

14 ‘‘(B) DISTRIBUTION OF MARKETING MATE15 RIALS.—The provisions of section

16 1932(d)(2)(B) of the Social Security Act re17 quiring the distribution of marketing materials

18 to an entire service area shall be deemed satis19 fied in the case of an Indian medicaid managed

20 care entity that distributes appropriate mate21 rials only to those Indians who are potentially

22 eligible to enroll with the entity in the service

23 area.

24 ‘‘(d) MALPRACTICE INSURANCE.—Insofar as, under

25 a medicaid managed care program, a health care provider
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•S 1057 IS

1 is required to have medical malpractice insurance coverage

2 as a condition of contracting as a provider with a medicaid

3 managed care entity, an Indian Health Program, or an

4 Urban Indian Organization that is a Federally-qualified

5 health center under title XIX of the Social Security Act,

6 that is covered under the Federal Tort Claims Act (28

7 U.S.C. 1346(b), 2671 et seq.) is deemed to satisfy such

8 requirement.

9 ‘‘(e) DEFINITIONS.—For purposes of this section:

10 ‘‘(1) MEDICAID MANAGED CARE ENTITY.—The

11 term ‘medicaid managed care entity’ means a man12 aged care entity (whether a managed care organiza13 tion or a primary care case manager) under title

14 XIX of the Social Security Act, whether pursuant to

15 section 1903(m) or section 1932 of such Act, a waiv16 er under section 1115 or 1915(b) of such Act, or

17 otherwise.

18 ‘‘(2) INDIAN MEDICAID MANAGED CARE EN19 TITY.—The term ‘Indian medicaid managed care en20 tity’ means a managed care entity that is controlled

21 (within the meaning of the last sentence of section

22 1903(m)(1)(C) of the Social Security Act) by the In23 dian Health Service, a Tribe, Tribal Organization, or

24 Urban Indian Organization (as such terms are de25 fined in section 4), or a consortium, which may be
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•S 1057 IS

1 composed of 1 or more Tribes, Tribal Organizations,

2 or Urban Indian Organizations, and which also may

3 include the Service.

4 ‘‘(3) NON-INDIAN MEDICAID MANAGED CARE

5 ENTITY.—The term ‘non-Indian medicaid managed

6 care entity’ means a medicaid managed care entity

7 that is not an Indian medicaid managed care entity.

8 ‘‘(4) COVERED MEDICAID MANAGED CARE

9 SERVICES.—The term ‘covered medicaid managed

10 care services’ means, with respect to an individual

11 enrolled with a medicaid managed care entity, items

12 and services that are within the scope of items and

13 services for which benefits are available with respect

14 to the individual under the contract between the en15 tity and the State involved.

16 ‘‘(5) MEDICAID MANAGED CARE PROGRAM.—

17 The term ‘medicaid managed care program’ means

18 a program under sections 1903(m) and 1932 of the

19 Social Security Act and includes a managed care

20 program operating under a waiver under section

21 1915(b) or 1115 of such Act or otherwise.

22 ‘‘SEC. 414. NAVAJO NATION MEDICAID AGENCY FEASIBIL23 ITY STUDY.

24 ‘‘(a) STUDY.—The Secretary shall conduct a study

25 to determine the feasibility of treating the Navajo Nation
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1 as a State for the purposes of title XIX of the Social Secu2 rity Act, to provide services to Indians living within the

3 boundaries of the Navajo Nation through an entity estab4 lished having the same authority and performing the same

5 functions as single-State medicaid agencies responsible for

6 the administration of the State plan under title XIX of

7 the Social Security Act.

8 ‘‘(b) CONSIDERATIONS.—In conducting the study,

9 the Secretary shall consider the feasibility of—

10 ‘‘(1) assigning and paying all expenditures for

11 the provision of services and related administration

12 funds, under title XIX of the Social Security Act, to

13 Indians living within the boundaries of the Navajo

14 Nation that are currently paid to or would otherwise

15 be paid to the State of Arizona, New Mexico, or

16 Utah;

17 ‘‘(2) providing assistance to the Navajo Nation

18 in the development and implementation of such en19 tity for the administration, eligibility, payment, and

20 delivery of medical assistance under title XIX of the

21 Social Security Act;

22 ‘‘(3) providing an appropriate level of matching

23 funds for Federal medical assistance with respect to

24 amounts such entity expends for medical assistance

25 for services and related administrative costs; and
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•S 1057 IS

1 ‘‘(4) authorizing the Secretary, at the option of

2 the Navajo Nation, to treat the Navajo Nation as a

3 State for the purposes of title XIX of the Social Se4 curity Act (relating to the State children’s health in5 surance program) under terms equivalent to those

6 described in paragraphs (2) through (4).

7 ‘‘(c) REPORT.—Not later then 3 years after the date

8 of enactment of the Indian Health Act Improvement Act

9 Amendments of 2005, the Secretary shall submit to the

10 Committee of Indian Affairs and Committee on Finance

11 of the Senate and the Committee on Resources and Com12 mittee on Ways and Means of the House of Representa13 tives a report that includes—

14 ‘‘(1) the results of the study under this section;

15 ‘‘(2) a summary of any consultation that oc16 curred between the Secretary and the Navajo Na17 tion, other Indian Tribes, the States of Arizona,

18 New Mexico, and Utah, counties which include Nav19 ajo Lands, and other interested parties, in conduct20 ing this study;

21 ‘‘(3) projected costs or savings associated with

22 establishment of such entity, and any estimated im23 pact on services provided as described in this section

24 in relation to probable costs or savings; and
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1 ‘‘(4) legislative actions that would be required

2 to authorize the establishment of such entity if such

3 entity is determined by the Secretary to be feasible.

4 ‘‘SEC. 415. AUTHORIZATION OF APPROPRIATIONS.

5 ‘‘There are authorized to be appropriated such sums

6 as may be necessary for each fiscal year through fiscal

7 year 2015 to carry out this title.

8 ‘‘TITLE V—HEALTH SERVICES

9 FOR URBAN INDIANS

10 ‘‘SEC. 501. PURPOSE.

11 ‘‘The purpose of this title is to establish and maintain

12 programs in Urban Centers to make health services more

13 accessible and available to Urban Indians.

14 ‘‘SEC. 502. CONTRACTS WITH, AND GRANTS TO, URBAN IN15 DIAN ORGANIZATIONS.

16 ‘‘Under authority of the Act of November 2, 1921

17 (25 U.S.C. 13) (commonly known as the ‘Snyder Act’),

18 the Secretary, acting through the Service, shall enter into

19 contracts with, or make grants to, Urban Indian Organi20 zations to assist such organizations in the establishment

21 and administration, within Urban Centers, of programs

22 which meet the requirements set forth in this title. Subject

23 to section 506, the Secretary, acting through the Service,

24 shall include such conditions as the Secretary considers

25 necessary to effect the purpose of this title in any contract
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1 into which the Secretary enters with, or in any grant the

2 Secretary makes to, any Urban Indian Organization pur3 suant to this title.

4 ‘‘SEC. 503. CONTRACTS AND GRANTS FOR THE PROVISION

5 OF HEALTH CARE AND REFERRAL SERVICES.

6 ‘‘(a) REQUIREMENTS FOR GRANTS AND CON7 TRACTS.—Under authority of the Act of November 2,

8 1921 (25 U.S.C. 13) (commonly known as the ‘Snyder

9 Act’), the Secretary, acting through the Service, shall

10 enter into contracts with, and make grants to, Urban In11 dian Organizations for the provision of health care and

12 referral services for Urban Indians. Any such contract or

13 grant shall include requirements that the Urban Indian

14 Organization successfully undertake to—

15 ‘‘(1) estimate the population of Urban Indians

16 residing in the Urban Center or centers that the or17 ganization proposes to serve who are or could be re18 cipients of health care or referral services;

19 ‘‘(2) estimate the current health status of

20 Urban Indians residing in such Urban Center or

21 centers;

22 ‘‘(3) estimate the current health care needs of

23 Urban Indians residing in such Urban Center or

24 centers;
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1 ‘‘(4) provide basic health education, including

2 health promotion and disease prevention education,

3 to Urban Indians;

4 ‘‘(5) make recommendations to the Secretary

5 and Federal, State, local, and other resource agen6 cies on methods of improving health service pro7 grams to meet the needs of Urban Indians; and

8 ‘‘(6) where necessary, provide, or enter into

9 contracts for the provision of, health care services

10 for Urban Indians.

11 ‘‘(b) CRITERIA.—The Secretary, acting through the

12 Service, shall by regulation adopted pursuant to section

13 520 prescribe the criteria for selecting Urban Indian Or14 ganizations to enter into contracts or receive grants under

15 this section. Such criteria shall, among other factors,

16 include—

17 ‘‘(1) the extent of unmet health care needs of

18 Urban Indians in the Urban Center or centers in19 volved;

20 ‘‘(2) the size of the Urban Indian population in

21 the Urban Center or centers involved;

22 ‘‘(3) the extent, if any, to which the activities

23 set forth in subsection (a) would duplicate any

24 project funded under this title;
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1 ‘‘(4) the capability of an Urban Indian Organi2 zation to perform the activities set forth in sub3 section (a) and to enter into a contract with the Sec4 retary or to meet the requirements for receiving a

5 grant under this section;

6 ‘‘(5) the satisfactory performance and success7 ful completion by an Urban Indian Organization of

8 other contracts with the Secretary under this title;

9 ‘‘(6) the appropriateness and likely effectiveness

10 of conducting the activities set forth in subsection

11 (a) in an Urban Center or centers; and

12 ‘‘(7) the extent of existing or likely future par13 ticipation in the activities set forth in subsection (a)

14 by appropriate health and health-related Federal,

15 State, local, and other agencies.

16 ‘‘(c) ACCESS TO HEALTH PROMOTION AND DISEASE

17 PREVENTION PROGRAMS.—The Secretary, acting through

18 the Service, shall facilitate access to or provide health pro19 motion and disease prevention services for Urban Indians

20 through grants made to Urban Indian Organizations ad21 ministering contracts entered into or receiving grants

22 under subsection (a).

23 ‘‘(d) IMMUNIZATION SERVICES.—

24 ‘‘(1) ACCESS OR SERVICES PROVIDED.—The

25 Secretary, acting through the Service, shall facilitate
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1 access to, or provide, immunization services for

2 Urban Indians through grants made to Urban In3 dian Organizations administering contracts entered

4 into or receiving grants under this section.

5 ‘‘(2) DEFINITION.—For purposes of this sub6 section, the term ‘immunization services’ means

7 services to provide without charge immunizations

8 against vaccine-preventable diseases.

9 ‘‘(e) BEHAVIORAL HEALTH SERVICES.—

10 ‘‘(1) ACCESS OR SERVICES PROVIDED.—The

11 Secretary, acting through the Service, shall facilitate

12 access to, or provide, behavioral health services for

13 Urban Indians through grants made to Urban In14 dian Organizations administering contracts entered

15 into or receiving grants under subsection (a).

16 ‘‘(2) ASSESSMENT REQUIRED.—Except as pro17 vided by paragraph (3)(A), a grant may not be made

18 under this subsection to an Urban Indian Organiza19 tion until that organization has prepared, and the

20 Service has approved, an assessment of the follow21 ing:

22 ‘‘(A) The behavioral health needs of the

23 Urban Indian population concerned.
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1 ‘‘(B) The behavioral health services and

2 other related resources available to that popu3 lation.

4 ‘‘(C) The barriers to obtaining those serv5 ices and resources.

6 ‘‘(D) The needs that are unmet by such

7 services and resources.

8 ‘‘(3) PURPOSES OF GRANTS.—Grants may be

9 made under this subsection for the following:

10 ‘‘(A) To prepare assessments required

11 under paragraph (2).

12 ‘‘(B) To provide outreach, educational, and

13 referral services to Urban Indians regarding the

14 availability of direct behavioral health services,

15 to educate Urban Indians about behavioral

16 health issues and services, and effect coordina17 tion with existing behavioral health providers in

18 order to improve services to Urban Indians.

19 ‘‘(C) To provide outpatient behavioral

20 health services to Urban Indians, including the

21 identification and assessment of illness, thera22 peutic treatments, case management, support

23 groups, family treatment, and other treatment.
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1 ‘‘(D) To develop innovative behavioral

2 health service delivery models which incorporate

3 Indian cultural support systems and resources.

4 ‘‘(f) PREVENTION OF CHILD ABUSE.—

5 ‘‘(1) ACCESS OR SERVICES PROVIDED.—The

6 Secretary, acting through the Service, shall facilitate

7 access to or provide services for Urban Indians

8 through grants to Urban Indian Organizations ad9 ministering contracts entered into or receiving

10 grants under subsection (a) to prevent and treat

11 child abuse (including sexual abuse) among Urban

12 Indians.

13 ‘‘(2) EVALUATION REQUIRED.—Except as pro14 vided by paragraph (3)(A), a grant may not be made

15 under this subsection to an Urban Indian Organiza16 tion until that organization has prepared, and the

17 Service has approved, an assessment that documents

18 the prevalence of child abuse in the Urban Indian

19 population concerned and specifies the services and

20 programs (which may not duplicate existing services

21 and programs) for which the grant is requested.

22 ‘‘(3) PURPOSES OF GRANTS.—Grants may be

23 made under this subsection for the following:

24 ‘‘(A) To prepare assessments required

25 under paragraph (2).
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1 ‘‘(B) For the development of prevention,

2 training, and education programs for Urban In3 dians, including child education, parent edu4 cation, provider training on identification and

5 intervention, education on reporting require6 ments, prevention campaigns, and establishing

7 service networks of all those involved in Indian

8 child protection.

9 ‘‘(C) To provide direct outpatient treat10 ment services (including individual treatment,

11 family treatment, group therapy, and support

12 groups) to Urban Indians who are child victims

13 of abuse (including sexual abuse) or adult sur14 vivors of child sexual abuse, to the families of

15 such child victims, and to Urban Indian per16 petrators of child abuse (including sexual

17 abuse).

18 ‘‘(4) CONSIDERATIONS WHEN MAKING

19 GRANTS.—In making grants to carry out this sub20 section, the Secretary shall take into consideration—

21 ‘‘(A) the support for the Urban Indian Or22 ganization demonstrated by the child protection

23 authorities in the area, including committees or

24 other services funded under the Indian Child
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1 Welfare Act of 1978 (25 U.S.C. 1901 et seq.),

2 if any;

3 ‘‘(B) the capability and expertise dem4 onstrated by the Urban Indian Organization to

5 address the complex problem of child sexual

6 abuse in the community; and

7 ‘‘(C) the assessment required under para8 graph (2).

9 ‘‘(g) OTHER GRANTS.—The Secretary, acting

10 through the Service, may enter into a contract with or

11 make grants to an Urban Indian Organization that pro12 vides or arranges for the provision of health care services

13 (through satellite facilities, provider networks, or other14 wise) to Urban Indians in more than 1 Urban Center.

15 ‘‘SEC. 504. CONTRACTS AND GRANTS FOR THE DETERMINA16 TION OF UNMET HEALTH CARE NEEDS.

17 ‘‘(a) GRANTS AND CONTRACTS AUTHORIZED.—

18 Under authority of the Act of November 2, 1921 (25

19 U.S.C. 13) (commonly known as the ‘Snyder Act’), the

20 Secretary, acting through the Service, may enter into con21 tracts with or make grants to Urban Indian Organizations

22 situated in Urban Centers for which contracts have not

23 been entered into or grants have not been made under sec24 tion 503.
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1 ‘‘(b) PURPOSE.—The purpose of a contract or grant

2 made under this section shall be the determination of the

3 matters described in subsection (c)(1) in order to assist

4 the Secretary in assessing the health status and health

5 care needs of Urban Indians in the Urban Center involved

6 and determining whether the Secretary should enter into

7 a contract or make a grant under section 503 with respect

8 to the Urban Indian Organization which the Secretary has

9 entered into a contract with, or made a grant to, under

10 this section.

11 ‘‘(c) GRANT AND CONTRACT REQUIREMENTS.—Any

12 contract entered into, or grant made, by the Secretary

13 under this section shall include requirements that—

14 ‘‘(1) the Urban Indian Organization success15 fully undertakes to—

16 ‘‘(A) document the health care status and

17 unmet health care needs of Urban Indians in

18 the Urban Center involved; and

19 ‘‘(B) with respect to Urban Indians in the

20 Urban Center involved, determine the matters

21 described in paragraphs (2), (3), (4), and (7) of

22 section 503(b); and

23 ‘‘(2) the Urban Indian Organization complete

24 performance of the contract, or carry out the re25 quirements of the grant, within 1 year after the date
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1 on which the Secretary and such organization enter

2 into such contract, or within 1 year after such orga3 nization receives such grant, whichever is applicable.

4 ‘‘(d) NO RENEWALS.—The Secretary may not renew

5 any contract entered into or grant made under this sec6 tion.

7 ‘‘SEC. 505. EVALUATIONS; RENEWALS.

8 ‘‘(a) PROCEDURES FOR EVALUATIONS.—The Sec9 retary, acting through the Service, shall develop proce10 dures to evaluate compliance with grant requirements and

11 compliance with and performance of contracts entered into

12 by Urban Indian Organizations under this title. Such pro13 cedures shall include provisions for carrying out the re14 quirements of this section.

15 ‘‘(b) EVALUATIONS.—The Secretary, acting through

16 the Service, shall evaluate the compliance of each Urban

17 Indian Organization which has entered into a contract or

18 received a grant under section 503 with the terms of such

19 contract or grant. For purposes of this evaluation, in de20 termining the capacity of an Urban Indian Organization

21 to deliver quality patient care the Secretary shall, at the

22 option of the organization—

23 ‘‘(1) acting through the Service, conduct an an24 nual onsite evaluation of the organization; or
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1 ‘‘(2) accept in lieu of such onsite evaluation evi2 dence of the organization’s provisional or full accred3 itation by a private independent entity recognized by

4 the Secretary for purposes of conducting quality re5 views of providers participating in the Medicare pro6 gram under title XVIII of the Social Security Act.

7 ‘‘(c) NONCOMPLIANCE; UNSATISFACTORY PERFORM8 ANCE.—If, as a result of the evaluations conducted under

9 this section, the Secretary determines that an Urban In10 dian Organization has not complied with the requirements

11 of a grant or complied with or satisfactorily performed a

12 contract under section 503, the Secretary shall, prior to

13 renewing such contract or grant, attempt to resolve with

14 the organization the areas of noncompliance or unsatisfac15 tory performance and modify the contract or grant to pre16 vent future occurrences of noncompliance or unsatisfac17 tory performance. If the Secretary determines that the

18 noncompliance or unsatisfactory performance cannot be

19 resolved and prevented in the future, the Secretary shall

20 not renew the contract or grant with the organization and

21 is authorized to enter into a contract or make a grant

22 under section 503 with another Urban Indian Organiza23 tion which is situated in the same Urban Center as the

24 Urban Indian Organization whose contract or grant is not

25 renewed under this section.
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1 ‘‘(d) CONSIDERATIONS FOR RENEWALS.—In deter2 mining whether to renew a contract or grant with an

3 Urban Indian Organization under section 503 which has

4 completed performance of a contract or grant under sec5 tion 504, the Secretary shall review the records of the

6 Urban Indian Organization, the reports submitted under

7 section 507, and shall consider the results of the onsite

8 evaluations or accreditations under subsection (b).

9 ‘‘SEC. 506. OTHER CONTRACT AND GRANT REQUIREMENTS.

10 ‘‘(a) PROCUREMENT.—Contracts with Urban Indian

11 Organizations entered into pursuant to this title shall be

12 in accordance with all Federal contracting laws and regu13 lations relating to procurement except that in the discre14 tion of the Secretary, such contracts may be negotiated

15 without advertising and need not conform to the provisions

16 of sections 1304 and 3131 through 3133 of title 40,

17 United States Code.

18 ‘‘(b) PAYMENTS UNDER CONTRACTS OR GRANTS.—

19 Payments under any contracts or grants pursuant to this

20 title shall, notwithstanding any term or condition of such

21 contract or grant—

22 ‘‘(1) be made in their entirety by the Secretary

23 to the Urban Indian Organization by no later than

24 the end of the first 30 days of the funding period

25 with respect to which the payments apply, unless the
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1 Secretary determines through an evaluation under

2 section 505 that the organization is not capable of

3 administering such payments in their entirety; and

4 ‘‘(2) if any portion thereof is unexpended by the

5 Urban Indian Organization during the funding pe6 riod with respect to which the payments initially

7 apply, shall be carried forward for expenditure with

8 respect to allowable or reimbursable costs incurred

9 by the organization during 1 or more subsequent

10 funding periods without additional justification or

11 documentation by the organization as a condition of

12 carrying forward the availability for expenditure of

13 such funds.

14 ‘‘(c) REVISION OR AMENDMENT OF CONTRACTS.—

15 Notwithstanding any provision of law to the contrary, the

16 Secretary may, at the request and consent of an Urban

17 Indian Organization, revise or amend any contract entered

18 into by the Secretary with such organization under this

19 title as necessary to carry out the purposes of this title.

20 ‘‘(d) FAIR AND UNIFORM SERVICES AND ASSIST21 ANCE.—Contracts with or grants to Urban Indian Organi22 zations and regulations adopted pursuant to this title shall

23 include provisions to assure the fair and uniform provision

24 to Urban Indians of services and assistance under such

25 contracts or grants by such organizations.
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1 ‘‘SEC. 507. REPORTS AND RECORDS.

2 ‘‘(a) REPORTS.—For each fiscal year during which

3 an Urban Indian Organization receives or expends funds

4 pursuant to a contract entered into or a grant received

5 pursuant to this title, such Urban Indian Organization

6 shall submit to the Secretary not more frequently than

7 every 6 months, a report that includes the following:

8 ‘‘(1) In the case of a contract or grant under

9 section 503, recommendations pursuant to section

10 503(a)(5).

11 ‘‘(2) Information on activities conducted by the

12 organization pursuant to the contract or grant.

13 ‘‘(3) An accounting of the amounts and purpose

14 for which Federal funds were expended.

15 ‘‘(4) A minimum set of data, using uniformly

16 defined elements, as specified by the Secretary after

17 consultation with Urban Indian Organizations.

18 ‘‘(b) AUDIT.—The reports and records of the Urban

19 Indian Organization with respect to a contract or grant

20 under this title shall be subject to audit by the Secretary

21 and the Comptroller General of the United States.

22 ‘‘(c) COSTS OF AUDITS.—The Secretary shall allow

23 as a cost of any contract or grant entered into or awarded

24 under section 502 or 503 the cost of an annual independ25 ent financial audit conducted by—

26 ‘‘(1) a certified public accountant; or
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1 ‘‘(2) a certified public accounting firm qualified

2 to conduct Federal compliance audits.

3 ‘‘SEC. 508. LIMITATION ON CONTRACT AUTHORITY.

4 ‘‘The authority of the Secretary to enter into con5 tracts or to award grants under this title shall be to the

6 extent, and in an amount, provided for in appropriation

7 Acts.

8 ‘‘SEC. 509. FACILITIES.

9 ‘‘(a) GRANTS.—The Secretary, acting through the

10 Service, may make grants to contractors or grant recipi11 ents under this title for the lease, purchase, renovation,

12 construction, or expansion of facilities, including leased fa13 cilities, in order to assist such contractors or grant recipi14 ents in complying with applicable licensure or certification

15 requirements.

16 ‘‘(b) LOAN FUND STUDY.—The Secretary, acting

17 through the Services, may carry out a study to determine

18 the feasibility of establishing a loan fund to provide to

19 Urban Indian Organizations direct loans or guarantees for

20 loans for the construction of health care facilities in a

21 manner consistent with section 309.

22 ‘‘SEC. 510. OFFICE OF URBAN INDIAN HEALTH.

23 ‘‘There is established within the Service an Office of

24 Urban Indian Health, which shall be responsible for—

25 ‘‘(1) carrying out the provisions of this title;
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1 ‘‘(2) providing central oversight of the pro2 grams and services authorized under this title; and

3 ‘‘(3) providing technical assistance to Urban In4 dian Organizations.

5 ‘‘SEC. 511. GRANTS FOR ALCOHOL AND SUBSTANCE ABUSE6 RELATED SERVICES.

7 ‘‘(a) GRANTS AUTHORIZED.—The Secretary, acting

8 through the Service, may make grants for the provision

9 of health-related services in prevention of, treatment of,

10 rehabilitation of, or school- and community-based edu11 cation regarding, alcohol and substance abuse in Urban

12 Centers to those Urban Indian Organizations with which

13 the Secretary has entered into a contract under this title

14 or under section 201.

15 ‘‘(b) GOALS.—Each grant made pursuant to sub16 section (a) shall set forth the goals to be accomplished

17 pursuant to the grant. The goals shall be specific to each

18 grant as agreed to between the Secretary and the grantee.

19 ‘‘(c) CRITERIA.—The Secretary shall establish cri20 teria for the grants made under subsection (a), including

21 criteria relating to the following:

22 ‘‘(1) The size of the Urban Indian population.

23 ‘‘(2) Capability of the organization to ade24 quately perform the activities required under the

25 grant.
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1 ‘‘(3) Satisfactory performance standards for the

2 organization in meeting the goals set forth in such

3 grant. The standards shall be negotiated and agreed

4 to between the Secretary and the grantee on a

5 grant-by-grant basis.

6 ‘‘(4) Identification of the need for services.

7 ‘‘(d) ALLOCATION OF GRANTS.—The Secretary shall

8 develop a methodology for allocating grants made pursu9 ant to this section based on the criteria established pursu10 ant to subsection (c).

11 ‘‘(e) GRANTS SUBJECT TO CRITERIA.—Any funds re12 ceived by an Urban Indian Organization under this Act

13 for substance abuse prevention, treatment, and rehabilita14 tion shall be subject to the criteria set forth in subsection

15 (c).

16 ‘‘SEC. 512. TREATMENT OF CERTAIN DEMONSTRATION

17 PROJECTS.

18 ‘‘Notwithstanding any other provision of law, the

19 Tulsa Clinic and Oklahoma City Clinic demonstration

20 projects shall—

21 ‘‘(1) be permanent programs within the Serv22 ice’s direct care program;

23 ‘‘(2) continue to be treated as Service Units in

24 the allocation of resources and coordination of care;

25 and
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1 ‘‘(3) continue to meet the requirements and

2 definitions of an urban Indian organization in this

3 Act, and shall not be subject to the provisions of the

4 Indian Self-Determination and Education Assistance

5 Act.

6 ‘‘SEC. 513. URBAN NIAAA TRANSFERRED PROGRAMS.

7 ‘‘(a) GRANTS AND CONTRACTS.—The Secretary,

8 through the Office of Urban Indian Health, shall make

9 grants or enter into contracts with Urban Indian Organi10 zations for the administration of Urban Indian alcohol

11 programs that were originally established under the Na12 tional Institute on Alcoholism and Alcohol Abuse (here13 after in this section referred to as ‘NIAAA’) and trans14 ferred to the Service. Such grants and contracts shall be15 come effective no later than September 30, 2008.

16 ‘‘(b) USE OF FUNDS.—Grants provided or contracts

17 entered into under this section shall be used to provide

18 support for the continuation of alcohol prevention and

19 treatment services for Urban Indian populations and such

20 other objectives as are agreed upon between the Service

21 and a recipient of a grant or contract under this section.

22 ‘‘(c) ELIGIBILITY.—Urban Indian Organizations that

23 operate Indian alcohol programs originally funded under

24 the NIAAA and subsequently transferred to the Service

25 are eligible for grants or contracts under this section.
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1 ‘‘(d) REPORT.—The Secretary shall evaluate and re2 port to Congress on the activities of programs funded

3 under this section not less than every 5 years.

4 ‘‘SEC. 514. CONSULTATION WITH URBAN INDIAN ORGANIZA5 TIONS.

6 ‘‘(a) IN GENERAL.—The Secretary shall ensure that

7 the Service consults, to the greatest extent practicable,

8 with Urban Indian Organizations.

9 ‘‘(b) DEFINITION OF CONSULTATION.—For purposes

10 of subsection (a), consultation is the open and free ex11 change of information and opinions which leads to mutual

12 understanding and comprehension and which emphasizes

13 trust, respect, and shared responsibility.

14 ‘‘SEC. 515. FEDERAL TORT CLAIM ACT COVERAGE.

15 ‘‘(a) IN GENERAL.—With respect to claims resulting

16 from the performance of functions during fiscal year 2005

17 and thereafter, or claims asserted after September 30,

18 2004, but resulting from the performance of functions

19 prior to fiscal year 2005, under a contract, grant agree20 ment, or any other agreement authorized under this title,

21 an Urban Indian Organization is deemed hereafter to be

22 part of the Service in the Department of Health and

23 Human Services while carrying out any such contract or

24 agreement and its employees are deemed employees of the

25 Service while acting within the scope of their employment
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1 in carrying out the contract or agreement. After Septem2 ber 30, 2003, any civil action or proceeding involving such

3 claims brought hereafter against any Urban Indian Orga4 nization or any employee of such Urban Indian Organiza5 tion covered by this provision shall be deemed to be an

6 action against the United States and will be defended by

7 the Attorney General and be afforded the full protection

8 and coverage of the Federal Tort Claims Act (28 U.S.C.

9 1346(b), 2671 et seq.). Future coverage under that Act

10 shall be contingent on cooperation of the Urban Indian

11 Organization with the Attorney General in prosecuting

12 past claims.

13 ‘‘(b) CLAIMS RESULTING FROM PERFORMANCE OF

14 CONTRACT OR GRANT.—Beginning for fiscal year 2005

15 and thereafter, the Secretary shall request through annual

16 appropriations funds sufficient to reimburse the Treasury

17 for any claims paid in the prior fiscal year pursuant to

18 the foregoing provisions.

19 ‘‘SEC. 516. URBAN YOUTH TREATMENT CENTER DEM20 ONSTRATION.

21 ‘‘(a) CONSTRUCTION AND OPERATION.—The Sec22 retary, acting through the Service, through grant or con23 tract, is authorized to fund the construction and operation

24 of at least 2 residential treatment centers in each State

25 described in subsection (b) to demonstrate the provision
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1 of alcohol and substance abuse treatment services to

2 Urban Indian youth in a culturally competent residential

3 setting.

4 ‘‘(b) DEFINITION OF STATE.—A State described in

5 this subsection is a State in which—

6 ‘‘(1) there resides Urban Indian youth with

7 need for alcohol and substance abuse treatment serv8 ices in a residential setting; and

9 ‘‘(2) there is a significant shortage of culturally

10 competent residential treatment services for Urban

11 Indian youth.

12 ‘‘SEC. 517. USE OF FEDERAL GOVERNMENT FACILITIES AND

13 SOURCES OF SUPPLY.

14 ‘‘(a) AUTHORIZATION FOR USE.—The Secretary, act15 ing through the Service, shall allow an Urban Indian Or16 ganization that has entered into a contract or received a

17 grant pursuant to this title, in carrying out such contract

18 or grant, to use existing facilities and all equipment there19 in or pertaining thereto and other personal property

20 owned by the Federal Government within the Secretary’s

21 jurisdiction under such terms and conditions as may be

22 agreed upon for their use and maintenance.

23 ‘‘(b) DONATIONS.—Subject to subsection (d), the

24 Secretary may donate to an Urban Indian Organization

25 that has entered into a contract or received a grant pursu-
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1 ant to this title any personal or real property determined

2 to be excess to the needs of the Service or the General

3 Services Administration for purposes of carrying out the

4 contract or grant.

5 ‘‘(c) ACQUISITION OF PROPERTY FOR DONATION.—

6 The Secretary may acquire excess or surplus government

7 personal or real property for donation (subject to sub8 section (d)), to an Urban Indian Organization that has

9 entered into a contract or received a grant pursuant to

10 this title if the Secretary determines that the property is

11 appropriate for use by the Urban Indian Organization for

12 a purpose for which a contract or grant is authorized

13 under this title.

14 ‘‘(d) PRIORITY.—In the event that the Secretary re15 ceives a request for donation of a specific item of personal

16 or real property described in subsection (b) or (c) from

17 both an Urban Indian Organization and from an Indian

18 Tribe or Tribal Organization, the Secretary shall give pri19 ority to the request for donation of the Indian Tribe or

20 Tribal Organization if the Secretary receives the request

21 from the Indian Tribe or Tribal Organization before the

22 date the Secretary transfers title to the property or, if ear23 lier, the date the Secretary transfers the property phys24 ically to the Urban Indian Organization.
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1 ‘‘(e) URBAN INDIAN ORGANIZATIONS DEEMED EX2 ECUTIVE AGENCY FOR CERTAIN PURPOSES.—For pur3 poses of section 501 of title 40, United States Code, (relat4 ing to Federal sources of supply, including lodging provid5 ers, airlines, and other transportation providers), an

6 Urban Indian Organization that has entered into a con7 tract or received a grant pursuant to this title shall be

8 deemed an executive agency when carrying out such con9 tract or grant.

10 ‘‘SEC. 518. GRANTS FOR DIABETES PREVENTION, TREAT11 MENT, AND CONTROL.

12 ‘‘(a) GRANTS AUTHORIZED.—The Secretary may

13 make grants to those Urban Indian Organizations that

14 have entered into a contract or have received a grant

15 under this title for the provision of services for the preven16 tion and treatment of, and control of the complications

17 resulting from, diabetes among Urban Indians.

18 ‘‘(b) GOALS.—Each grant made pursuant to sub19 section (a) shall set forth the goals to be accomplished

20 under the grant. The goals shall be specific to each grant

21 as agreed to between the Secretary and the grantee.

22 ‘‘(c) ESTABLISHMENT OF CRITERIA.—The Secretary

23 shall establish criteria for the grants made under sub24 section (a) relating to—
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1 ‘‘(1) the size and location of the Urban Indian

2 population to be served;

3 ‘‘(2) the need for prevention of and treatment

4 of, and control of the complications resulting from,

5 diabetes among the Urban Indian population to be

6 served;

7 ‘‘(3) performance standards for the organiza8 tion in meeting the goals set forth in such grant

9 that are negotiated and agreed to by the Secretary

10 and the grantee;

11 ‘‘(4) the capability of the organization to ade12 quately perform the activities required under the

13 grant; and

14 ‘‘(5) the willingness of the organization to col15 laborate with the registry, if any, established by the

16 Secretary under section 204(e) in the Area Office of

17 the Service in which the organization is located.

18 ‘‘(d) FUNDS SUBJECT TO CRITERIA.—Any funds re19 ceived by an Urban Indian Organization under this Act

20 for the prevention, treatment, and control of diabetes

21 among Urban Indians shall be subject to the criteria devel22 oped by the Secretary under subsection (c).

23 ‘‘SEC. 519. COMMUNITY HEALTH REPRESENTATIVES.

24 ‘‘The Secretary, acting through the Service, may

25 enter into contracts with, and make grants to, Urban In-
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1 dian Organizations for the employment of Indians trained

2 as health service providers through the Community Health

3 Representatives Program under section 109 in the provi4 sion of health care, health promotion, and disease preven5 tion services to Urban Indians.

6 ‘‘SEC. 520. REGULATIONS.

7 ‘‘(a) REQUIREMENTS FOR REGULATIONS.—The Sec8 retary may promulgate regulations to implement the provi9 sions of this title in accordance with the following:

10 ‘‘(1) Proposed regulations to implement this

11 Act shall be published in the Federal Register by the

12 Secretary no later than 9 months after the date of

13 enactment of this Act and shall have no less than a

14 4-month comment period.

15 ‘‘(2) The authority to promulgate regulations

16 under this Act shall expire 18 months from the date

17 of enactment of this Act.

18 ‘‘(b) EFFECTIVE DATE OF TITLE.—The amendments

19 to this title made by the Indian Health Care Improvement

20 Act Amendments of 2005 shall be effective on the date

21 of enactment of such amendments, regardless of whether

22 the Secretary has promulgated regulations implementing

23 such amendments have been promulgated.
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1 ‘‘SEC. 521. ELIGIBILITY FOR SERVICES.

2 ‘‘Urban Indians shall be eligible and the ultimate

3 beneficiaries for health care or referral services provided

4 pursuant to this title.

5 ‘‘SEC. 522. AUTHORIZATION OF APPROPRIATIONS.

6 ‘‘There are authorized to be appropriated such sums

7 as may be necessary for each fiscal year through fiscal

8 year 2015 to carry out this title.

9 ‘‘TITLE VI—ORGANIZATIONAL

10 IMPROVEMENTS

11 ‘‘SEC. 601. ESTABLISHMENT OF THE INDIAN HEALTH SERV12 ICE AS AN AGENCY OF THE PUBLIC HEALTH

13 SERVICE.

14 ‘‘(a) ESTABLISHMENT.—

15 ‘‘(1) IN GENERAL.—In order to more effectively

16 and efficiently carry out the responsibilities, authori17 ties, and functions of the United States to provide

18 health care services to Indians and Indian Tribes, as

19 are or may be hereafter provided by Federal statute

20 or treaties, there is established within the Public

21 Health Service of the Department the Indian Health

22 Service.

23 ‘‘(2) ASSISTANT SECRETARY OF INDIAN

24 HEALTH.—The Service shall be administered by an

25 Assistant Secretary of Indian Health, who shall be

26 appointed by the President, by and with the advice
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1 and consent of the Senate. The Assistant Secretary

2 shall report to the Secretary. Effective with respect

3 to an individual appointed by the President, by and

4 with the advice and consent of the Senate, after

5 January 1, 2005, the term of service of the Assist6 ant Secretary shall be 4 years. An Assistant Sec7 retary may serve more than 1 term.

8 ‘‘(3) INCUMBENT.—The individual serving in

9 the position of Director of the Indian Health Service

10 on the day before the date of enactment of the In11 dian Health Care Improvement Act Amendments of

12 2005 shall serve as Assistant Secretary.

13 ‘‘(4) ADVOCACY AND CONSULTATION.—The po14 sition of Assistant Secretary is established to, in a

15 manner consistent with the government-to-govern16 ment relationship between the United States and In17 dian Tribes—

18 ‘‘(A) facilitate advocacy for the develop19 ment of appropriate Indian health policy; and

20 ‘‘(B) promote consultation on matters re21 lating to Indian health.

22 ‘‘(b) AGENCY.—The Service shall be an agency within

23 the Public Health Service of the Department, and shall

24 not be an office, component, or unit of any other agency

25 of the Department.
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1 ‘‘(c) DUTIES.—The Assistant Secretary of Indian

2 Health shall—

3 ‘‘(1) perform all functions that were, on the day

4 before the date of enactment of the Indian Health

5 Care Improvement Act Amendments of 2005, car6 ried out by or under the direction of the individual

7 serving as Director of the Service on that day;

8 ‘‘(2) perform all functions of the Secretary re9 lating to the maintenance and operation of hospital

10 and health facilities for Indians and the planning

11 for, and provision and utilization of, health services

12 for Indians;

13 ‘‘(3) administer all health programs under

14 which health care is provided to Indians based upon

15 their status as Indians which are administered by

16 the Secretary, including programs under—

17 ‘‘(A) this Act;

18 ‘‘(B) the Act of November 2, 1921 (25

19 U.S.C. 13);

20 ‘‘(C) the Act of August 5, 1954 (42 U.S.C.

21 2001 et seq.);

22 ‘‘(D) the Act of August 16, 1957 (42

23 U.S.C. 2005 et seq.); and
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1 ‘‘(E) the Indian Self-Determination and

2 Education Assistance Act (25 U.S.C. 450 et

3 seq.);

4 ‘‘(4) administer all scholarship and loan func5 tions carried out under title I;

6 ‘‘(5) report directly to the Secretary concerning

7 all policy- and budget-related matters affecting In8 dian health;

9 ‘‘(6) collaborate with the Assistant Secretary

10 for Health concerning appropriate matters of Indian

11 health that affect the agencies of the Public Health

12 Service;

13 ‘‘(7) advise each Assistant Secretary of the De14 partment concerning matters of Indian health with

15 respect to which that Assistant Secretary has au16 thority and responsibility;

17 ‘‘(8) advise the heads of other agencies and pro18 grams of the Department concerning matters of In19 dian health with respect to which those heads have

20 authority and responsibility;

21 ‘‘(9) coordinate the activities of the Department

22 concerning matters of Indian health; and

23 ‘‘(10) perform such other functions as the Sec24 retary may designate.

25 ‘‘(d) AUTHORITY.—
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1 ‘‘(1) IN GENERAL.—The Secretary, acting

2 through the Assistant Secretary, shall have the

3 authority—

4 ‘‘(A) except to the extent provided for in

5 paragraph (2), to appoint and compensate em6 ployees for the Service in accordance with title

7 5, United States Code;

8 ‘‘(B) to enter into contracts for the pro9 curement of goods and services to carry out the

10 functions of the Service; and

11 ‘‘(C) to manage, expend, and obligate all

12 funds appropriated for the Service.

13 ‘‘(2) PERSONNEL ACTIONS.—Notwithstanding

14 any other provision of law, the provisions of section

15 12 of the Act of June 18, 1934 (48 Stat. 986; 25

16 U.S.C. 472), shall apply to all personnel actions

17 taken with respect to new positions created within

18 the Service as a result of its establishment under

19 subsection (a).

20 ‘‘(e) REFERENCES.—Any reference to the Director of

21 the Indian Health Service in any other Federal law, Exec22 utive order, rule, regulation, or delegation of authority, or

23 in any document of or relating to the Director of the In24 dian Health Service, shall be deemed to refer to the Assist25 ant Secretary.
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1 ‘‘SEC. 602. AUTOMATED MANAGEMENT INFORMATION SYS2 TEM.

3 ‘‘(a) ESTABLISHMENT.—

4 ‘‘(1) IN GENERAL.—The Secretary shall estab5 lish an automated management information system

6 for the Service.

7 ‘‘(2) REQUIREMENTS OF SYSTEM.—The infor8 mation system established under paragraph (1) shall

9 include—

10 ‘‘(A) a financial management system;

11 ‘‘(B) a patient care information system for

12 each area served by the Service;

13 ‘‘(C) a privacy component that protects the

14 privacy of patient information held by, or on be15 half of, the Service;

16 ‘‘(D) a services-based cost accounting com17 ponent that provides estimates of the costs as18 sociated with the provision of specific medical

19 treatments or services in each Area office of the

20 Service;

21 ‘‘(E) an interface mechanism for patient

22 billing and accounts receivable system; and

23 ‘‘(F) a training component.

24 ‘‘(b) PROVISION OF SYSTEMS TO TRIBES AND ORGA25 NIZATIONS.—The Secretary shall provide each Tribal
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1 Health Program automated management information sys2 tems which—

3 ‘‘(1) meet the management information needs

4 of such Tribal Health Program with respect to the

5 treatment by the Tribal Health Program of patients

6 of the Service; and

7 ‘‘(2) meet the management information needs

8 of the Service.

9 ‘‘(c) ACCESS TO RECORDS.—Notwithstanding any

10 other provision of law, each patient shall have reasonable

11 access to the medical or health records of such patient

12 which are held by, or on behalf of, the Service.

13 ‘‘(d) AUTHORITY TO ENHANCE INFORMATION TECH14 NOLOGY.—The Secretary, acting through the Assistant

15 Secretary, shall have the authority to enter into contracts,

16 agreements, or joint ventures with other Federal agencies,

17 States, private and nonprofit organizations, for the pur18 pose of enhancing information technology in Indian health

19 programs and facilities.

20 ‘‘SEC. 603. AUTHORIZATION OF APPROPRIATIONS.

21 ‘‘There is authorized to be appropriated such sums

22 as may be necessary for each fiscal year through fiscal

23 year 2015 to carry out this title.
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1 ‘‘TITLE VII—BEHAVIORAL

2 HEALTH PROGRAMS

3 ‘‘SEC. 701. BEHAVIORAL HEALTH PREVENTION AND TREAT4 MENT SERVICES.

5 ‘‘(a) PURPOSES.—The purposes of this section are as

6 follows:

7 ‘‘(1) To authorize and direct the Secretary, act8 ing through the Service, Indian Tribes, Tribal Orga9 nizations, and Urban Indian Organizations, to de10 velop a comprehensive behavioral health prevention

11 and treatment program which emphasizes collabora12 tion among alcohol and substance abuse, social serv13 ices, and mental health programs.

14 ‘‘(2) To provide information, direction, and

15 guidance relating to mental illness and dysfunction

16 and self-destructive behavior, including child abuse

17 and family violence, to those Federal, tribal, State,

18 and local agencies responsible for programs in In19 dian communities in areas of health care, education,

20 social services, child and family welfare, alcohol and

21 substance abuse, law enforcement, and judicial serv22 ices.

23 ‘‘(3) To assist Indian Tribes to identify services

24 and resources available to address mental illness and

25 dysfunctional and self-destructive behavior.
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1 ‘‘(4) To provide authority and opportunities for

2 Indian Tribes and Tribal Organizations to develop,

3 implement, and coordinate with community-based

4 programs which include identification, prevention,

5 education, referral, and treatment services, including

6 through multidisciplinary resource teams.

7 ‘‘(5) To ensure that Indians, as citizens of the

8 United States and of the States in which they re9 side, have the same access to behavioral health serv10 ices to which all citizens have access.

11 ‘‘(6) To modify or supplement existing pro12 grams and authorities in the areas identified in

13 paragraph (2).

14 ‘‘(b) PLANS.—

15 ‘‘(1) DEVELOPMENT.—The Secretary, acting

16 through the Service, Indian Tribes, Tribal Organiza17 tions, and Urban Indian Organizations, shall encour18 age Indian Tribes and Tribal Organizations to de19 velop tribal plans, and Urban Indian Organizations

20 to develop local plans, and for all such groups to

21 participate in developing areawide plans for Indian

22 Behavioral Health Services. The plans shall include,

23 to the extent feasible, the following components:

24 ‘‘(A) An assessment of the scope of alcohol

25 or other substance abuse, mental illness, and
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1 dysfunctional and self-destructive behavior, in2 cluding suicide, child abuse, and family vio3 lence, among Indians, including—

4 ‘‘(i) the number of Indians served who

5 are directly or indirectly affected by such

6 illness or behavior; or

7 ‘‘(ii) an estimate of the financial and

8 human cost attributable to such illness or

9 behavior.

10 ‘‘(B) An assessment of the existing and

11 additional resources necessary for the preven12 tion and treatment of such illness and behavior,

13 including an assessment of the progress toward

14 achieving the availability of the full continuum

15 of care described in subsection (c).

16 ‘‘(C) An estimate of the additional funding

17 needed by the Service, Indian Tribes, Tribal

18 Organizations, and Urban Indian Organizations

19 to meet their responsibilities under the plans.

20 ‘‘(2) NATIONAL CLEARINGHOUSE.—The Sec21 retary, acting through the Service, shall establish a

22 national clearinghouse of plans and reports on the

23 outcomes of such plans developed by Indian Tribes,

24 Tribal Organizations, Urban Indian Organizations,

25 and Service Areas relating to behavioral health. The
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1 Secretary shall ensure access to these plans and out2 comes by any Indian Tribe, Tribal Organization,

3 Urban Indian Organization, or the Service.

4 ‘‘(3) TECHNICAL ASSISTANCE.—The Secretary

5 shall provide technical assistance to Indian Tribes,

6 Tribal Organizations, and Urban Indian Organiza7 tions in preparation of plans under this section and

8 in developing standards of care that may be used

9 and adopted locally.

10 ‘‘(c) PROGRAMS.—The Secretary, acting through the

11 Service, Indian Tribes, and Tribal Organizations, shall

12 provide, to the extent feasible and if funding is available,

13 programs including the following:

14 ‘‘(1) COMPREHENSIVE CARE.—A comprehensive

15 continuum of behavioral health care which

16 provides—

17 ‘‘(A) community-based prevention, inter18 vention, outpatient, and behavioral health

19 aftercare;

20 ‘‘(B) detoxification (social and medical);

21 ‘‘(C) acute hospitalization;

22 ‘‘(D) intensive outpatient/day treatment;

23 ‘‘(E) residential treatment;
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1 ‘‘(F) transitional living for those needing a

2 temporary, stable living environment that is

3 supportive of treatment and recovery goals;

4 ‘‘(G) emergency shelter;

5 ‘‘(H) intensive case management;

6 ‘‘(I) Traditional Health Care Practices;

7 and

8 ‘‘(J) diagnostic services.

9 ‘‘(2) CHILD CARE.—Behavioral health services

10 for Indians from birth through age 17, including—

11 ‘‘(A) preschool and school age fetal alcohol

12 disorder services, including assessment and be13 havioral intervention;

14 ‘‘(B) mental health and substance abuse

15 services (emotional, organic, alcohol, drug, in16 halant, and tobacco);

17 ‘‘(C) identification and treatment of co-oc18 curring disorders and comorbidity;

19 ‘‘(D) prevention of alcohol, drug, inhalant,

20 and tobacco use;

21 ‘‘(E) early intervention, treatment, and

22 aftercare;

23 ‘‘(F) promotion of healthy approaches to

24 risk and safety issues; and
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1 ‘‘(G) identification and treatment of ne2 glect and physical, mental, and sexual abuse.

3 ‘‘(3) ADULT CARE.—Behavioral health services

4 for Indians from age 18 through 55, including—

5 ‘‘(A) early intervention, treatment, and

6 aftercare;

7 ‘‘(B) mental health and substance abuse

8 services (emotional, alcohol, drug, inhalant, and

9 tobacco), including sex specific services;

10 ‘‘(C) identification and treatment of co-oc11 curring disorders (dual diagnosis) and co12 morbidity;

13 ‘‘(D) promotion of healthy approaches for

14 risk-related behavior;

15 ‘‘(E) treatment services for women at risk

16 of giving birth to a child with a fetal alcohol

17 disorder; and

18 ‘‘(F) sex specific treatment for sexual as19 sault and domestic violence.

20 ‘‘(4) FAMILY CARE.—Behavioral health services

21 for families, including—

22 ‘‘(A) early intervention, treatment, and

23 aftercare for affected families;

24 ‘‘(B) treatment for sexual assault and do25 mestic violence; and
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1 ‘‘(C) promotion of healthy approaches re2 lating to parenting, domestic violence, and other

3 abuse issues.

4 ‘‘(5) ELDER CARE.—Behavioral health services

5 for Indians 56 years of age and older, including—

6 ‘‘(A) early intervention, treatment, and

7 aftercare;

8 ‘‘(B) mental health and substance abuse

9 services (emotional, alcohol, drug, inhalant, and

10 tobacco), including sex specific services;

11 ‘‘(C) identification and treatment of co-oc12 curring disorders (dual diagnosis) and co13 morbidity;

14 ‘‘(D) promotion of healthy approaches to

15 managing conditions related to aging;

16 ‘‘(E) sex specific treatment for sexual as17 sault, domestic violence, neglect, physical and

18 mental abuse and exploitation; and

19 ‘‘(F) identification and treatment of de20 mentias regardless of cause.

21 ‘‘(d) COMMUNITY BEHAVIORAL HEALTH PLAN.—

22 ‘‘(1) ESTABLISHMENT.—The governing body of

23 any Indian Tribe, Tribal Organization, or Urban In24 dian Organization may adopt a resolution for the es25 tablishment of a community behavioral health plan
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1 providing for the identification and coordination of

2 available resources and programs to identify, pre3 vent, or treat substance abuse, mental illness, or

4 dysfunctional and self-destructive behavior, including

5 child abuse and family violence, among its members

6 or its service population. This plan should include

7 behavioral health services, social services, intensive

8 outpatient services, and continuing aftercare.

9 ‘‘(2) TECHNICAL ASSISTANCE.—At the request

10 of an Indian Tribe, Tribal Organization, or Urban

11 Indian Organization, the Bureau of Indian Affairs

12 and the Service shall cooperate with and provide

13 technical assistance to the Indian Tribe, Tribal Or14 ganization, or Urban Indian Organization in the de15 velopment and implementation of such plan.

16 ‘‘(3) FUNDING.—The Secretary, acting through

17 the Service, may make funding available to Indian

18 Tribes and Tribal Organizations which adopt a reso19 lution pursuant to paragraph (1) to obtain technical

20 assistance for the development of a community be21 havioral health plan and to provide administrative

22 support in the implementation of such plan.

23 ‘‘(e) COORDINATION FOR AVAILABILITY OF SERV24 ICES.—The Secretary, acting through the Service, Indian

25 Tribes, Tribal Organizations, and Urban Indian Organiza-
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1 tions, shall coordinate behavioral health planning, to the

2 extent feasible, with other Federal agencies and with State

3 agencies, to encourage comprehensive behavioral health

4 services for Indians regardless of their place of residence.

5 ‘‘(f) MENTAL HEALTH CARE NEED ASSESSMENT.—

6 Not later than 1 year after the date of enactment of the

7 Indian Health Care Improvement Act Amendments of

8 2005, the Secretary, acting through the Service, shall

9 make an assessment of the need for inpatient mental

10 health care among Indians and the availability and cost

11 of inpatient mental health facilities which can meet such

12 need. In making such assessment, the Secretary shall con13 sider the possible conversion of existing, underused Service

14 hospital beds into psychiatric units to meet such need.

15 ‘‘SEC. 702. MEMORANDA OF AGREEMENT WITH THE DE16 PARTMENT OF THE INTERIOR.

17 ‘‘(a) CONTENTS.—Not later than 12 months after the

18 date of enactment of the Indian Health Care Improvement

19 Act Amendments of 2005, the Secretary, acting through

20 the Service, and the Secretary of the Interior shall develop

21 and enter into a memoranda of agreement, or review and

22 update any existing memoranda of agreement, as required

23 by section 4205 of the Indian Alcohol and Substance

24 Abuse Prevention and Treatment Act of 1986 (25 U.S.C.

25 2411) under which the Secretaries address the following:
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1 ‘‘(1) The scope and nature of mental illness and

2 dysfunctional and self-destructive behavior, including

3 child abuse and family violence, among Indians.

4 ‘‘(2) The existing Federal, tribal, State, local,

5 and private services, resources, and programs avail6 able to provide behavioral health services for Indi7 ans.

8 ‘‘(3) The unmet need for additional services, re9 sources, and programs necessary to meet the needs

10 identified pursuant to paragraph (1).

11 ‘‘(4)(A) The right of Indians, as citizens of the

12 United States and of the States in which they re13 side, to have access to behavioral health services to

14 which all citizens have access.

15 ‘‘(B) The right of Indians to participate in, and

16 receive the benefit of, such services.

17 ‘‘(C) The actions necessary to protect the exer18 cise of such right.

19 ‘‘(5) The responsibilities of the Bureau of In20 dian Affairs and the Service, including mental illness

21 identification, prevention, education, referral, and

22 treatment services (including services through multi23 disciplinary resource teams), at the central, area,

24 and agency and Service Unit, Service Area, and
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1 headquarters levels to address the problems identi2 fied in paragraph (1).

3 ‘‘(6) A strategy for the comprehensive coordina4 tion of the behavioral health services provided by the

5 Bureau of Indian Affairs and the Service to meet

6 the problems identified pursuant to paragraph (1),

7 including—

8 ‘‘(A) the coordination of alcohol and sub9 stance abuse programs of the Service, the Bu10 reau of Indian Affairs, and Indian Tribes and

11 Tribal Organizations (developed under the In12 dian Alcohol and Substance Abuse Prevention

13 and Treatment Act of 1986) with behavioral

14 health initiatives pursuant to this Act, particu15 larly with respect to the referral and treatment

16 of dually diagnosed individuals requiring behav17 ioral health and substance abuse treatment; and

18 ‘‘(B) ensuring that the Bureau of Indian

19 Affairs and Service programs and services (in20 cluding multidisciplinary resource teams) ad21 dressing child abuse and family violence are co22 ordinated with such non-Federal programs and

23 services.

24 ‘‘(7) Directing appropriate officials of the Bu25 reau of Indian Affairs and the Service, particularly
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1 at the agency and Service Unit levels, to cooperate

2 fully with tribal requests made pursuant to commu3 nity behavioral health plans adopted under section

4 701(c) and section 4206 of the Indian Alcohol and

5 Substance Abuse Prevention and Treatment Act of

6 1986 (25 U.S.C. 2412).

7 ‘‘(8) Providing for an annual review of such

8 agreement by the Secretaries which shall be provided

9 to Congress and Indian Tribes and Tribal Organiza10 tions.

11 ‘‘(b) SPECIFIC PROVISIONS REQUIRED.—The memo12 randa of agreement updated or entered into pursuant to

13 subsection (a) shall include specific provisions pursuant to

14 which the Service shall assume responsibility for—

15 ‘‘(1) the determination of the scope of the prob16 lem of alcohol and substance abuse among Indians,

17 including the number of Indians within the jurisdic18 tion of the Service who are directly or indirectly af19 fected by alcohol and substance abuse and the finan20 cial and human cost;

21 ‘‘(2) an assessment of the existing and needed

22 resources necessary for the prevention of alcohol and

23 substance abuse and the treatment of Indians af24 fected by alcohol and substance abuse; and
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1 ‘‘(3) an estimate of the funding necessary to

2 adequately support a program of prevention of alco3 hol and substance abuse and treatment of Indians

4 affected by alcohol and substance abuse.

5 ‘‘(c) CONSULTATION.—The Secretary, acting through

6 the Service, and the Secretary of the Interior shall, in de7 veloping the memoranda of agreement under subsection

8 (a), consult with and solicit the comments from—

9 ‘‘(1) Indian Tribes and Tribal Organizations;

10 ‘‘(2) Indians;

11 ‘‘(3) Urban Indian Organizations and other In12 dian organizations; and

13 ‘‘(4) behavioral health service providers.

14 ‘‘(d) PUBLICATION.—Each memorandum of agree15 ment entered into or renewed (and amendments or modi16 fications thereto) under subsection (a) shall be published

17 in the Federal Register. At the same time as publication

18 in the Federal Register, the Secretary shall provide a copy

19 of such memoranda, amendment, or modification to each

20 Indian Tribe, Tribal Organization, and Urban Indian Or21 ganization.

22 ‘‘SEC. 703. COMPREHENSIVE BEHAVIORAL HEALTH PRE23 VENTION AND TREATMENT PROGRAM.

24 ‘‘(a) ESTABLISHMENT.—
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1 ‘‘(1) IN GENERAL.—The Secretary, acting

2 through the Service, Indian Tribes, and Tribal Orga3 nizations, shall provide a program of comprehensive

4 behavioral health, prevention, treatment, and

5 aftercare, including Traditional Health Care Prac6 tices, which shall include—

7 ‘‘(A) prevention, through educational inter8 vention, in Indian communities;

9 ‘‘(B) acute detoxification, psychiatric hos10 pitalization, residential, and intensive outpatient

11 treatment;

12 ‘‘(C) community-based rehabilitation and

13 aftercare;

14 ‘‘(D) community education and involve15 ment, including extensive training of health

16 care, educational, and community-based person17 nel;

18 ‘‘(E) specialized residential treatment pro19 grams for high-risk populations, including preg20 nant and postpartum women and their children;

21 and

22 ‘‘(F) diagnostic services.

23 ‘‘(2) TARGET POPULATIONS.—The target popu24 lation of such programs shall be members of Indian

25 Tribes. Efforts to train and educate key members of
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1 the Indian community shall also target employees of

2 health, education, judicial, law enforcement, legal,

3 and social service programs.

4 ‘‘(b) CONTRACT HEALTH SERVICES.—

5 ‘‘(1) IN GENERAL.—The Secretary, acting

6 through the Service, Indian Tribes, and Tribal Orga7 nizations, may enter into contracts with public or

8 private providers of behavioral health treatment

9 services for the purpose of carrying out the program

10 required under subsection (a).

11 ‘‘(2) PROVISION OF ASSISTANCE.—In carrying

12 out this subsection, the Secretary shall provide as13 sistance to Indian Tribes and Tribal Organizations

14 to develop criteria for the certification of behavioral

15 health service providers and accreditation of service

16 facilities which meet minimum standards for such

17 services and facilities.

18 ‘‘SEC. 704. MENTAL HEALTH TECHNICIAN PROGRAM.

19 ‘‘(a) IN GENERAL.—Under the authority of the Act

20 of November 2, 1921 (25 U.S.C. 13) (commonly known

21 as the ‘Snyder Act’), the Secretary shall establish and

22 maintain a mental health technician program within the

23 Service which—

24 ‘‘(1) provides for the training of Indians as

25 mental health technicians; and
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1 ‘‘(2) employs such technicians in the provision

2 of community-based mental health care that includes

3 identification, prevention, education, referral, and

4 treatment services.

5 ‘‘(b) PARAPROFESSIONAL TRAINING.—In carrying

6 out subsection (a), the Secretary, acting through the Serv7 ice, Indian Tribes, and Tribal Organizations, shall provide

8 high-standard paraprofessional training in mental health

9 care necessary to provide quality care to the Indian com10 munities to be served. Such training shall be based upon

11 a curriculum developed or approved by the Secretary

12 which combines education in the theory of mental health

13 care with supervised practical experience in the provision

14 of such care.

15 ‘‘(c) SUPERVISION AND EVALUATION OF TECHNI16 CIANS.—The Secretary, acting through the Service, Indian

17 Tribes, and Tribal Organizations, shall supervise and

18 evaluate the mental health technicians in the training pro19 gram.

20 ‘‘(d) TRADITIONAL HEALTH CARE PRACTICES.—The

21 Secretary, acting through the Service, shall ensure that

22 the program established pursuant to this subsection in23 volves the use and promotion of the Traditional Health

24 Care Practices of the Indian Tribes to be served.
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1 ‘‘SEC. 705. LICENSING REQUIREMENT FOR MENTAL

2 HEALTH CARE WORKERS.

3 ‘‘Subject to the provisions of section 221, any person

4 employed as a psychologist, social worker, or marriage and

5 family therapist for the purpose of providing mental health

6 care services to Indians in a clinical setting under this Act

7 is required to be licensed as a clinical psychologist, social

8 worker, or marriage and family therapist, respectively, or

9 working under the direct supervision of a licensed clinical

10 psychologist, social worker, or marriage and family thera11 pist, respectively.

12 ‘‘SEC. 706. INDIAN WOMEN TREATMENT PROGRAMS.

13 ‘‘(a) FUNDING.—The Secretary, consistent with sec14 tion 701, shall make funds available to Indian Tribes,

15 Tribal Organizations, and Urban Indian Organizations to

16 develop and implement a comprehensive behavioral health

17 program of prevention, intervention, treatment, and re18 lapse prevention services that specifically addresses the

19 spiritual, cultural, historical, social, and child care needs

20 of Indian women, regardless of age.

21 ‘‘(b) USE OF FUNDS.—Funds made available pursu22 ant to this section may be used to—

23 ‘‘(1) develop and provide community training,

24 education, and prevention programs for Indian

25 women relating to behavioral health issues, including

26 fetal alcohol disorders;
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1 ‘‘(2) identify and provide psychological services,

2 counseling, advocacy, support, and relapse preven3 tion to Indian women and their families; and

4 ‘‘(3) develop prevention and intervention models

5 for Indian women which incorporate Traditional

6 Health Care Practices, cultural values, and commu7 nity and family involvement.

8 ‘‘(c) CRITERIA.—The Secretary, in consultation with

9 Indian Tribes and Tribal Organizations, shall establish

10 criteria for the review and approval of applications and

11 proposals for funding under this section.

12 ‘‘(d) EARMARK OF CERTAIN FUNDS.—Twenty per13 cent of the funds appropriated pursuant to this section

14 shall be used to make grants to Urban Indian Organiza15 tions.

16 ‘‘SEC. 707. INDIAN YOUTH PROGRAM.

17 ‘‘(a) DETOXIFICATION AND REHABILITATION.—The

18 Secretary, acting through the Service, consistent with sec19 tion 701, shall develop and implement a program for acute

20 detoxification and treatment for Indian youths, including

21 behavioral health services. The program shall include re22 gional treatment centers designed to include detoxification

23 and rehabilitation for both sexes on a referral basis and

24 programs developed and implemented by Indian Tribes or

25 Tribal Organizations at the local level under the Indian
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1 Self-Determination and Education Assistance Act. Re2 gional centers shall be integrated with the intake and re3 habilitation programs based in the referring Indian com4 munity.

5 ‘‘(b) ALCOHOL AND SUBSTANCE ABUSE TREATMENT

6 CENTERS OR FACILITIES.—

7 ‘‘(1) ESTABLISHMENT.—

8 ‘‘(A) IN GENERAL.—The Secretary, acting

9 through the Service, Indian Tribes, and Tribal

10 Organizations, shall construct, renovate, or, as

11 necessary, purchase, and appropriately staff

12 and operate, at least 1 youth regional treatment

13 center or treatment network in each area under

14 the jurisdiction of an Area Office.

15 ‘‘(B) AREA OFFICE IN CALIFORNIA.—For

16 the purposes of this subsection, the Area Office

17 in California shall be considered to be 2 Area

18 Offices, 1 office whose jurisdiction shall be con19 sidered to encompass the northern area of the

20 State of California, and 1 office whose jurisdic21 tion shall be considered to encompass the re22 mainder of the State of California for the pur23 pose of implementing California treatment net24 works.
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1 ‘‘(2) FUNDING.—For the purpose of staffing

2 and operating such centers or facilities, funding

3 shall be pursuant to the Act of November 2, 1921

4 (25 U.S.C. 13).

5 ‘‘(3) LOCATION.—A youth treatment center

6 constructed or purchased under this subsection shall

7 be constructed or purchased at a location within the

8 area described in paragraph (1) agreed upon (by ap9 propriate tribal resolution) by a majority of the In10 dian Tribes to be served by such center.

11 ‘‘(4) SPECIFIC PROVISION OF FUNDS.—

12 ‘‘(A) IN GENERAL.—Notwithstanding any

13 other provision of this title, the Secretary may,

14 from amounts authorized to be appropriated for

15 the purposes of carrying out this section, make

16 funds available to—

17 ‘‘(i) the Tanana Chiefs Conference,

18 Incorporated, for the purpose of leasing,

19 constructing, renovating, operating, and

20 maintaining a residential youth treatment

21 facility in Fairbanks, Alaska; and

22 ‘‘(ii) the Southeast Alaska Regional

23 Health Corporation to staff and operate a

24 residential youth treatment facility without

25 regard to the proviso set forth in section
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1 4(l) of the Indian Self-Determination and

2 Education Assistance Act (25 U.S.C.

3 450b(l)).

4 ‘‘(B) PROVISION OF SERVICES TO ELIGI5 BLE YOUTHS.—Until additional residential

6 youth treatment facilities are established in

7 Alaska pursuant to this section, the facilities

8 specified in subparagraph (A) shall make every

9 effort to provide services to all eligible Indian

10 youths residing in Alaska.

11 ‘‘(c) INTERMEDIATE ADOLESCENT BEHAVIORAL

12 HEALTH SERVICES.—

13 ‘‘(1) IN GENERAL.—The Secretary, acting

14 through the Service, Indian Tribes, and Tribal Orga15 nizations, may provide intermediate behavioral

16 health services, which may incorporate Traditional

17 Health Care Practices, to Indian children and ado18 lescents, including—

19 ‘‘(A) pretreatment assistance;

20 ‘‘(B) inpatient, outpatient, and aftercare

21 services;

22 ‘‘(C) emergency care;

23 ‘‘(D) suicide prevention and crisis interven24 tion; and
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1 ‘‘(E) prevention and treatment of mental

2 illness and dysfunctional and self-destructive

3 behavior, including child abuse and family vio4 lence.

5 ‘‘(2) USE OF FUNDS.—Funds provided under

6 this subsection may be used—

7 ‘‘(A) to construct or renovate an existing

8 health facility to provide intermediate behav9 ioral health services;

10 ‘‘(B) to hire behavioral health profes11 sionals;

12 ‘‘(C) to staff, operate, and maintain an in13 termediate mental health facility, group home,

14 sober housing, transitional housing or similar

15 facilities, or youth shelter where intermediate

16 behavioral health services are being provided;

17 ‘‘(D) to make renovations and hire appro18 priate staff to convert existing hospital beds

19 into adolescent psychiatric units; and

20 ‘‘(E) for intensive home- and community21 based services.

22 ‘‘(3) CRITERIA.—The Secretary, acting through

23 the Service, shall, in consultation with Indian Tribes

24 and Tribal Organizations, establish criteria for the
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1 review and approval of applications or proposals for

2 funding made available pursuant to this subsection.

3 ‘‘(d) FEDERALLY OWNED STRUCTURES.—

4 ‘‘(1) IN GENERAL.—The Secretary, in consulta5 tion with Indian Tribes and Tribal Organizations,

6 shall—

7 ‘‘(A) identify and use, where appropriate,

8 federally owned structures suitable for local res9 idential or regional behavioral health treatment

10 for Indian youths; and

11 ‘‘(B) establish guidelines, in consultation

12 with Indian Tribes and Tribal Organizations,

13 for determining the suitability of any such fed14 erally owned structure to be used for local resi15 dential or regional behavioral health treatment

16 for Indian youths.

17 ‘‘(2) TERMS AND CONDITIONS FOR USE OF

18 STRUCTURE.—Any structure described in paragraph

19 (1) may be used under such terms and conditions as

20 may be agreed upon by the Secretary and the agency

21 having responsibility for the structure and any In22 dian Tribe or Tribal Organization operating the pro23 gram.

24 ‘‘(e) REHABILITATION AND AFTERCARE SERVICES.—
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1 ‘‘(1) IN GENERAL.—The Secretary, Indian

2 Tribes, or Tribal Organizations, in cooperation with

3 the Secretary of the Interior, shall develop and im4 plement within each Service Unit, community-based

5 rehabilitation and follow-up services for Indian

6 youths who are having significant behavioral health

7 problems, and require long-term treatment, commu8 nity reintegration, and monitoring to support the In9 dian youths after their return to their home commu10 nity.

11 ‘‘(2) ADMINISTRATION.—Services under para12 graph (1) shall be provided by trained staff within

13 the community who can assist the Indian youths in

14 their continuing development of self-image, positive

15 problem-solving skills, and nonalcohol or substance

16 abusing behaviors. Such staff may include alcohol

17 and substance abuse counselors, mental health pro18 fessionals, and other health professionals and para19 professionals, including community health represent20 atives.

21 ‘‘(f) INCLUSION OF FAMILY IN YOUTH TREATMENT

22 PROGRAM.—In providing the treatment and other services

23 to Indian youths authorized by this section, the Secretary,

24 acting through the Service, Indian Tribes, and Tribal Or25 ganizations, shall provide for the inclusion of family mem-
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1 bers of such youths in the treatment programs or other

2 services as may be appropriate. Not less than 10 percent

3 of the funds appropriated for the purposes of carrying out

4 subsection (e) shall be used for outpatient care of adult

5 family members related to the treatment of an Indian

6 youth under that subsection.

7 ‘‘(g) MULTIDRUG ABUSE PROGRAM.—The Secretary,

8 acting through the Service, Indian Tribes, Tribal Organi9 zations, and Urban Indian Organizations, shall provide,

10 consistent with section 701, programs and services to pre11 vent and treat the abuse of multiple forms of substances,

12 including alcohol, drugs, inhalants, and tobacco, among

13 Indian youths residing in Indian communities, on or near

14 reservations, and in urban areas and provide appropriate

15 mental health services to address the incidence of mental

16 illness among such youths.

17 ‘‘SEC. 708. INPATIENT AND COMMUNITY-BASED MENTAL

18 HEALTH FACILITIES DESIGN, CONSTRUC19 TION, AND STAFFING.

20 ‘‘Not later than 1 year after the date of enactment

21 of the Indian Health Care Improvement Act Amendments

22 of 2005, the Secretary, acting through the Service, Indian

23 Tribes, and Tribal Organizations, may provide, in each

24 area of the Service, not less than 1 inpatient mental health

25 care facility, or the equivalent, for Indians with behavioral
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1 health problems. For the purposes of this subsection, Cali2 fornia shall be considered to be 2 Area Offices, 1 office

3 whose location shall be considered to encompass the north4 ern area of the State of California and 1 office whose ju5 risdiction shall be considered to encompass the remainder

6 of the State of California. The Secretary shall consider

7 the possible conversion of existing, underused Service hos8 pital beds into psychiatric units to meet such need.

9 ‘‘SEC. 709. TRAINING AND COMMUNITY EDUCATION.

10 ‘‘(a) PROGRAM.—The Secretary, in cooperation with

11 the Secretary of the Interior, shall develop and implement

12 or provide funding for Indian Tribes and Tribal Organiza13 tions to develop and implement, within each Service Unit

14 or tribal program, a program of community education and

15 involvement which shall be designed to provide concise and

16 timely information to the community leadership of each

17 tribal community. Such program shall include education

18 about behavioral health issues to political leaders, Tribal

19 judges, law enforcement personnel, members of tribal

20 health and education boards, health care providers includ21 ing traditional practitioners, and other critical members

22 of each tribal community. Community-based training (ori23 ented toward local capacity development) shall also include

24 tribal community provider training (designed for adult
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1 learners from the communities receiving services for pre2 vention, intervention, treatment, and aftercare).

3 ‘‘(b) INSTRUCTION.—The Secretary, acting through

4 the Service, shall, either directly or through Indian Tribes

5 and Tribal Organizations, provide instruction in the area

6 of behavioral health issues, including instruction in crisis

7 intervention and family relations in the context of alcohol

8 and substance abuse, child sexual abuse, youth alcohol and

9 substance abuse, and the causes and effects of fetal alco10 hol disorders to appropriate employees of the Bureau of

11 Indian Affairs and the Service, and to personnel in schools

12 or programs operated under any contract with the Bureau

13 of Indian Affairs or the Service, including supervisors of

14 emergency shelters and halfway houses described in sec15 tion 4213 of the Indian Alcohol and Substance Abuse Pre16 vention and Treatment Act of 1986 (25 U.S.C. 2433).

17 ‘‘(c) TRAINING MODELS.—In carrying out the edu18 cation and training programs required by this section, the

19 Secretary, in consultation with Indian Tribes, Tribal Or20 ganizations, Indian behavioral health experts, and Indian

21 alcohol and substance abuse prevention experts, shall de22 velop and provide community-based training models. Such

23 models shall address—

24 ‘‘(1) the elevated risk of alcohol and behavioral

25 health problems faced by children of alcoholics;
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1 ‘‘(2) the cultural, spiritual, and

2 multigenerational aspects of behavioral health prob3 lem prevention and recovery; and

4 ‘‘(3) community-based and multidisciplinary

5 strategies for preventing and treating behavioral

6 health problems.

7 ‘‘SEC. 710. BEHAVIORAL HEALTH PROGRAM.

8 ‘‘(a) INNOVATIVE PROGRAMS.—The Secretary, acting

9 through the Service, Indian Tribes, and Tribal Organiza10 tions, consistent with section 701, may plan, develop, im11 plement, and carry out programs to deliver innovative

12 community-based behavioral health services to Indians.

13 ‘‘(b) FUNDING; CRITERIA.—The Secretary may

14 award such funding for a project under subsection (a) to

15 an Indian Tribe or Tribal Organization and may consider

16 the following criteria:

17 ‘‘(1) The project will address significant unmet

18 behavioral health needs among Indians.

19 ‘‘(2) The project will serve a significant number

20 of Indians.

21 ‘‘(3) The project has the potential to deliver

22 services in an efficient and effective manner.

23 ‘‘(4) The Indian Tribe or Tribal Organization

24 has the administrative and financial capability to ad25 minister the project.
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1 ‘‘(5) The project may deliver services in a man2 ner consistent with Traditional Health Care Prac3 tices.

4 ‘‘(6) The project is coordinated with, and avoids

5 duplication of, existing services.

6 ‘‘(c) EQUITABLE TREATMENT.—For purposes of this

7 subsection, the Secretary shall, in evaluating project appli8 cations or proposals, use the same criteria that the Sec9 retary uses in evaluating any other application or proposal

10 for such funding.

11 ‘‘SEC. 711. FETAL ALCOHOL DISORDER FUNDING.

12 ‘‘(a) PROGRAMS.—

13 ‘‘(1) ESTABLISHMENT.—The Secretary, consist14 ent with section 701, acting through the Service, In15 dian Tribes, and Tribal Organizations, is authorized

16 to establish and operate fetal alcohol disorder pro17 grams as provided in this section for the purposes

18 of meeting the health status objectives specified in

19 section 3.

20 ‘‘(2) USE OF FUNDS.—Funding provided pursu21 ant to this section shall be used for the following:

22 ‘‘(A) To develop and provide for Indians

23 community and in school training, education,

24 and prevention programs relating to fetal alco25 hol disorders.
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1 ‘‘(B) To identify and provide behavioral

2 health treatment to high-risk Indian women

3 and high-risk women pregnant with an Indian’s

4 child.

5 ‘‘(C) To identify and provide appropriate

6 psychological services, educational and voca7 tional support, counseling, advocacy, and infor8 mation to fetal alcohol disorder affected Indians

9 and their families or caretakers.

10 ‘‘(D) To develop and implement counseling

11 and support programs in schools for fetal alco12 hol disorder affected Indian children.

13 ‘‘(E) To develop prevention and interven14 tion models which incorporate practitioners of

15 Traditional Health Care Practices, cultural and

16 spiritual values, and community involvement.

17 ‘‘(F) To develop, print, and disseminate

18 education and prevention materials on fetal al19 cohol disorder.

20 ‘‘(G) To develop and implement, through

21 the tribal consultation process, culturally sen22 sitive assessment and diagnostic tools including

23 dysmorphology clinics and multidisciplinary

24 fetal alcohol disorder clinics for use in Indian

25 communities and Urban Centers.
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1 ‘‘(H) To develop early childhood interven2 tion projects from birth on to mitigate the ef3 fects of fetal alcohol disorder among Indians.

4 ‘‘(I) To develop and fund community-based

5 adult fetal alcohol disorder housing and support

6 services for Indians and for women pregnant

7 with an Indian’s child.

8 ‘‘(3) CRITERIA FOR APPLICATIONS.—The Sec9 retary shall establish criteria for the review and ap10 proval of applications for funding under this section.

11 ‘‘(b) SERVICES.—The Secretary, acting through the

12 Service and Indian Tribes, Tribal Organizations, and

13 Urban Indian Organizations, shall—

14 ‘‘(1) develop and provide services for the pre15 vention, intervention, treatment, and aftercare for

16 those affected by fetal alcohol disorder in Indian

17 communities; and

18 ‘‘(2) provide supportive services, directly or

19 through an Indian Tribe, Tribal Organization, or

20 Urban Indian Organization, including services to

21 meet the special educational, vocational, school-to22 work transition, and independent living needs of ad23 olescent and adult Indians with fetal alcohol dis24 order.
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1 ‘‘(c) TASK FORCE.—The Secretary shall establish a

2 task force to be known as the Fetal Alcohol Disorder Task

3 Force to advise the Secretary in carrying out subsection

4 (b). Such task force shall be composed of representatives

5 from the following:

6 ‘‘(1) The National Institute on Drug Abuse.

7 ‘‘(2) The National Institute on Alcohol and Al8 coholism.

9 ‘‘(3) The Office of Substance Abuse Prevention.

10 ‘‘(4) The National Institute of Mental Health.

11 ‘‘(5) The Service.

12 ‘‘(6) The Office of Minority Health of the De13 partment of Health and Human Services.

14 ‘‘(7) The Administration for Native Americans.

15 ‘‘(8) The National Institute of Child Health

16 and Human Development (NICHD).

17 ‘‘(9) The Centers for Disease Control and Pre18 vention.

19 ‘‘(10) The Bureau of Indian Affairs.

20 ‘‘(11) Indian Tribes.

21 ‘‘(12) Tribal Organizations.

22 ‘‘(13) Urban Indian Organizations.

23 ‘‘(14) Indian fetal alcohol disorder experts.

24 ‘‘(d) APPLIED RESEARCH PROJECTS.—The Sec25 retary, acting through the Substance Abuse and Mental
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1 Health Services Administration, shall make funding avail2 able to Indian Tribes, Tribal Organizations, and Urban

3 Indian Organizations for applied research projects which

4 propose to elevate the understanding of methods to pre5 vent, intervene, treat, or provide rehabilitation and behav6 ioral health aftercare for Indians and Urban Indians af7 fected by fetal alcohol disorder.

8 ‘‘(e) FUNDING FOR URBAN INDIAN ORGANIZA9 TIONS.—Ten percent of the funds appropriated pursuant

10 to this section shall be used to make grants to Urban In11 dian Organizations funded under title V.

12 ‘‘SEC. 712. CHILD SEXUAL ABUSE AND PREVENTION TREAT13 MENT PROGRAMS.

14 ‘‘(a) ESTABLISHMENT.—The Secretary, acting

15 through the Service, and the Secretary of the Interior, In16 dian Tribes, and Tribal Organizations shall establish, con17 sistent with section 701, in every Service Area, programs

18 involving treatment for—

19 ‘‘(1) victims of sexual abuse who are Indian

20 children or children in an Indian household; and

21 ‘‘(2) perpetrators of child sexual abuse who are

22 Indian or members of an Indian household.

23 ‘‘(b) USE OF FUNDS.—Funding provided pursuant to

24 this section shall be used for the following:
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1 ‘‘(1) To develop and provide community edu2 cation and prevention programs related to sexual

3 abuse of Indian children or children in an Indian

4 household.

5 ‘‘(2) To identify and provide behavioral health

6 treatment to victims of sexual abuse who are Indian

7 children or children in an Indian household, and to

8 their family members who are affected by sexual

9 abuse.

10 ‘‘(3) To develop prevention and intervention

11 models which incorporate Traditional Health Care

12 Practices, cultural and spiritual values, and commu13 nity involvement.

14 ‘‘(4) To develop and implement, through the

15 tribal consultation process, culturally sensitive as16 sessment and diagnostic tools for use in Indian com17 munities and Urban Centers.

18 ‘‘(5) To identify and provide behavioral health

19 treatment to Indian perpetrators and perpetrators

20 who are members of an Indian household—

21 ‘‘(A) making efforts to begin offender and

22 behavioral health treatment while the perpetra23 tor is incarcerated or at the earliest possible

24 date if the perpetrator is not incarcerated; and
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1 ‘‘(B) providing treatment after the per2 petrator is released, until it is determined that

3 the perpetrator is not a threat to children.

4 ‘‘SEC. 713. BEHAVIORAL HEALTH RESEARCH.

5 ‘‘The Secretary, in consultation with appropriate

6 Federal agencies, shall provide funding to Indian Tribes,

7 Tribal Organizations, and Urban Indian Organizations or

8 enter into contracts with, or make grants to appropriate

9 institutions for, the conduct of research on the incidence

10 and prevalence of behavioral health problems among Indi11 ans served by the Service, Indian Tribes, or Tribal Organi12 zations and among Indians in urban areas. Research pri13 orities under this section shall include—

14 ‘‘(1) the interrelationship and interdependence

15 of behavioral health problems with alcoholism and

16 other substance abuse, suicide, homicides, other in17 juries, and the incidence of family violence; and

18 ‘‘(2) the development of models of prevention

19 techniques.

20 The effect of the interrelationships and interdependencies

21 referred to in paragraph (1) on children, and the develop22 ment of prevention techniques under paragraph (2) appli23 cable to children, shall be emphasized.
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1 ‘‘SEC. 714. DEFINITIONS.

2 ‘‘For the purpose of this title, the following defini3 tions shall apply:

4 ‘‘(1) ASSESSMENT.—The term ‘assessment’

5 means the systematic collection, analysis, and dis6 semination of information on health status, health

7 needs, and health problems.

8 ‘‘(2) ALCOHOL-RELATED

9 NEURODEVELOPMENTAL DISORDERS OR ARND.—The

10 term ‘alcohol-related neurodevelopmental disorders’

11 or ‘ARND’ means, with a history of maternal alco12 hol consumption during pregnancy, central nervous

13 system involvement such as developmental delay, in14 tellectual deficit, or neurologic abnormalities. Behav15 iorally, there can be problems with irritability, and

16 failure to thrive as infants. As children become older

17 there will likely be hyperactivity, attention deficit,

18 language dysfunction, and perceptual and judgment

19 problems.

20 ‘‘(3) BEHAVIORAL HEALTH AFTERCARE.—The

21 term ‘behavioral health aftercare’ includes those ac22 tivities and resources used to support recovery fol23 lowing inpatient, residential, intensive substance

24 abuse, or mental health outpatient or outpatient

25 treatment. The purpose is to help prevent or deal

26 with relapse by ensuring that by the time a client or
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1 patient is discharged from a level of care, such as

2 outpatient treatment, an aftercare plan has been de3 veloped with the client. An aftercare plan may use

4 such resources a as community-based therapeutic

5 group, transitional living facilities, a 12-step spon6 sor, a local 12-step or other related support group,

7 and other community-based providers (mental health

8 professionals, traditional health care practitioners,

9 community health aides, community health rep10 resentatives, mental health technicians, ministers,

11 etc.)

12 ‘‘(4) DUAL DIAGNOSIS.—The term ‘dual diag13 nosis’ means coexisting substance abuse and mental

14 illness conditions or diagnosis. Such clients are

15 sometimes referred to as mentally ill chemical abus16 ers (MICAs).

17 ‘‘(5) FETAL ALCOHOL DISORDERS.—The term

18 ‘fetal alcohol disorders’ means fetal alcohol syn19 drome, partial fetal alcohol syndrome and alcohol re20 lated neurodevelopmental disorder (ARND).

21 ‘‘(6) FETAL ALCOHOL SYNDROME OR FAS.—

22 The term ‘fetal alcohol syndrome’ or ‘FAS’ means a

23 syndrome in which, with a history of maternal alco24 hol consumption during pregnancy, the following cri25 teria are met:
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1 ‘‘(A) Central nervous system involvement

2 such as developmental delay, intellectual deficit,

3 microencephaly, or neurologic abnormalities.

4 ‘‘(B) Craniofacial abnormalities with at

5 least 2 of the following: microophthalmia, short

6 palpebral fissures, poorly developed philtrum,

7 thin upper lip, flat nasal bridge, and short

8 upturned nose.

9 ‘‘(C) Prenatal or postnatal growth delay.

10 ‘‘(7) PARTIAL FAS.—The term ‘partial FAS’

11 means, with a history of maternal alcohol consump12 tion during pregnancy, having most of the criteria of

13 FAS, though not meeting a minimum of at least 2

14 of the following: microophthalmia, short palpebral

15 fissures, poorly developed philtrum, thin upper lip,

16 flat nasal bridge, and short upturned nose.

17 ‘‘(8) REHABILITATION.—The term ‘rehabilita18 tion’ means to restore the ability or capacity to en19 gage in usual and customary life activities through

20 education and therapy.

21 ‘‘(9) SUBSTANCE ABUSE.—The term ‘substance

22 abuse’ includes inhalant abuse.
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1 ‘‘SEC. 715. AUTHORIZATION OF APPROPRIATIONS.

2 ‘‘There is authorized to be appropriated such sums

3 as may be necessary for each fiscal year through fiscal

4 year 2015 to carry out the provisions of this title.

5 ‘‘TITLE VIII—MISCELLANEOUS

6 ‘‘SEC. 801. REPORTS.

7 ‘‘The President shall, at the time the budget is sub8 mitted under section 1105 of title 31, United States Code,

9 for each fiscal year transmit to Congress a report contain10 ing the following:

11 ‘‘(1) A report on the progress made in meeting

12 the objectives of this Act, including a review of pro13 grams established or assisted pursuant to this Act

14 and assessments and recommendations of additional

15 programs or additional assistance necessary to, at a

16 minimum, provide health services to Indians and en17 sure a health status for Indians, which are at a par18 ity with the health services available to and the

19 health status of the general population, including

20 specific comparisons of appropriations provided and

21 those required for such parity.

22 ‘‘(2) A report on whether, and to what extent,

23 new national health care programs, benefits, initia24 tives, or financing systems have had an impact on

25 the purposes of this Act and any steps that the Sec26 retary may have taken to consult with Indian Tribes,
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1 Tribal Organizations, and Urban Indian Organiza2 tions to address such impact, including a report on

3 proposed changes in allocation of funding pursuant

4 to section 808.

5 ‘‘(3) A report on the use of health services by

6 Indians—

7 ‘‘(A) on a national and area or other rel8 evant geographical basis;

9 ‘‘(B) by gender and age;

10 ‘‘(C) by source of payment and type of

11 service;

12 ‘‘(D) comparing such rates of use with

13 rates of use among comparable non-Indian pop14 ulations; and

15 ‘‘(E) provided under contracts.

16 ‘‘(4) A report of contractors to the Secretary on

17 Health Care Educational Loan Repayments every 6

18 months required by section 110.

19 ‘‘(5) A general audit report of the Secretary on

20 the Health Care Educational Loan Repayment Pro21 gram as required by section 110(n).

22 ‘‘(6) A report of the findings and conclusions of

23 demonstration programs on development of edu24 cational curricula for substance abuse counseling as

25 required in section 125(f).
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1 ‘‘(7) A separate statement which specifies the

2 amount of funds requested to carry out the provi3 sions of section 201.

4 ‘‘(8) A report of the evaluations of health pro5 motion and disease prevention as required in section

6 203(c).

7 ‘‘(9) A biennial report to Congress on infectious

8 diseases as required by section 212.

9 ‘‘(10) A report on environmental and nuclear

10 health hazards as required by section 215.

11 ‘‘(11) An annual report on the status of all

12 health care facilities needs as required by section

13 301(c)(2) and 301(d).

14 ‘‘(12) Reports on safe water and sanitary waste

15 disposal facilities as required by section 302(h).

16 ‘‘(13) An annual report on the expenditure of

17 nonservice funds for renovation as required by sec18 tions 304(b)(2).

19 ‘‘(14) A report identifying the backlog of main20 tenance and repair required at Service and tribal fa21 cilities required by section 313(a).

22 ‘‘(15) A report providing an accounting of reim23 bursement funds made available to the Secretary

24 under titles XVIII, XIX, and XXI of the Social Se25 curity Act.
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1 ‘‘(16) A report on any arrangements for the

2 sharing of medical facilities or services, as author3 ized by section 406.

4 ‘‘(17) A report on evaluation and renewal of

5 Urban Indian programs under section 505.

6 ‘‘(18) A report on the evaluation of programs

7 as required by section 513(d).

8 ‘‘(19) A report on alcohol and substance abuse

9 as required by section 701(f).

10 ‘‘SEC. 802. REGULATIONS.

11 ‘‘(a) DEADLINES.—

12 ‘‘(1) PROCEDURES.—Not later than 90 days

13 after the date of enactment of the Indian Health

14 Care Improvement Act Amendments of 2005, the

15 Secretary shall initiate procedures under subchapter

16 III of chapter 5 of title 5, United States Code, to

17 negotiate and promulgate such regulations or

18 amendments thereto that are necessary to carry out

19 titles I (except sections 105, 115, and 117), II, III,

20 and VII. The Secretary may promulgate regulations

21 to carry out sections 105, 115, 117, and titles IV

22 and V, using the procedures required by chapter V

23 of title 5, United States Code (commonly known as

24 the ‘Administrative Procedure Act’). The Secretary
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1 shall issue no regulations to carry out titles VI and

2 VIII.

3 ‘‘(2) PROPOSED REGULATIONS.—Proposed reg4 ulations to implement this Act shall be published in

5 the Federal Register by the Secretary no later than

6 1 year after the date of enactment of the Indian

7 Health Care Improvement Act Amendments of 2005

8 and shall have no less than a 120-day comment pe9 riod.

10 ‘‘(3) EXPIRATION OF AUTHORITY.—Except as

11 otherwise provided herein, the authority to promul12 gate regulations under this Act shall expire 24

13 months from the date of enactment of this Act.

14 ‘‘(b) COMMITTEE.—A negotiated rulemaking commit15 tee established pursuant to section 565 of title 5, United

16 States Code, to carry out this section shall have as its

17 members only representatives of the Federal Government

18 and representatives of Indian Tribes and Tribal Organiza19 tions, a majority of whom shall be nominated by and be

20 representatives of Indian Tribes, Tribal Organizations,

21 and Urban Indian Organizations from each Service Area.

22 The representative of the Urban Indian Organization shall

23 be deemed to be an elected officer of a tribal government

24 for purposes of applying section 204(b) of the Unfunded

25 Mandates Reform Act of 1995 (2 U.S.C. 1534(b)).
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1 ‘‘(c) ADAPTATION OF PROCEDURES.—The Secretary

2 shall adapt the negotiated rulemaking procedures to the

3 unique context of self-governance and the government-to4 government relationship between the United States and

5 Indian Tribes.

6 ‘‘(d) LACK OF REGULATIONS.—The lack of promul7 gated regulations shall not limit the effect of this Act.

8 ‘‘(e) INCONSISTENT REGULATIONS.—The provisions

9 of this Act shall supersede any conflicting provisions of

10 law) in effect on the day before the date of enactment of

11 the Indian Health Care Improvement Act Amendments of

12 2005, and the Secretary is authorized to repeal any regu13 lation inconsistent with the provisions of this Act.

14 ‘‘SEC. 803. PLAN OF IMPLEMENTATION.

15 ‘‘Not later than 9 months after the date of enactment

16 of the Indian Health Care Improvement Act Amendments

17 of 2005, the Secretary in consultation with Indian Tribes,

18 Tribal Organizations, and Urban Indian Organizations,

19 shall submit to Congress a plan explaining the manner and

20 schedule (including a schedule of appropriation requests),

21 by title and section, by which the Secretary will implement

22 the provisions of this Act.

23 ‘‘SEC. 804. AVAILABILITY OF FUNDS.

24 ‘‘The funds appropriated pursuant to this Act shall

25 remain available until expended.
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1 ‘‘SEC. 805. LIMITATION ON USE OF FUNDS APPROPRIATED

2 TO THE INDIAN HEALTH SERVICE.

3 ‘‘Any limitation on the use of funds contained in an

4 Act providing appropriations for the Department for a pe5 riod with respect to the performance of abortions shall

6 apply for that period with respect to the performance of

7 abortions using funds contained in an Act providing ap8 propriations for the Service.

9 ‘‘SEC. 806. ELIGIBILITY OF CALIFORNIA INDIANS.

10 ‘‘(a) IN GENERAL.—The following California Indians

11 shall be eligible for health services provided by the Service:

12 ‘‘(1) Any member of a federally recognized In13 dian Tribe.

14 ‘‘(2) Any descendant of an Indian who was re15 siding in California on June 1, 1852, if such

16 descendant—

17 ‘‘(A) is a member of the Indian community

18 served by a local program of the Service; and

19 ‘‘(B) is regarded as an Indian by the com20 munity in which such descendant lives.

21 ‘‘(3) Any Indian who holds trust interests in

22 public domain, national forest, or reservation allot23 ments in California.

24 ‘‘(4) Any Indian in California who is listed on

25 the plans for distribution of the assets of rancherias

26 and reservations located within the State of Califor-
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1 nia under the Act of August 18, 1958 (72 Stat.

2 619), and any descendant of such an Indian.

3 ‘‘(b) CLARIFICATION.—Nothing in this section may

4 be construed as expanding the eligibility of California Indi5 ans for health services provided by the Service beyond the

6 scope of eligibility for such health services that applied on

7 May 1, 1986.

8 ‘‘SEC. 807. HEALTH SERVICES FOR INELIGIBLE PERSONS.

9 ‘‘(a) CHILDREN.—Any individual who—

10 ‘‘(1) has not attained 19 years of age;

11 ‘‘(2) is the natural or adopted child, stepchild,

12 foster child, legal ward, or orphan of an eligible In13 dian; and

14 ‘‘(3) is not otherwise eligible for health services

15 provided by the Service,

16 shall be eligible for all health services provided by the

17 Service on the same basis and subject to the same rules

18 that apply to eligible Indians until such individual attains

19 19 years of age. The existing and potential health needs

20 of all such individuals shall be taken into consideration

21 by the Service in determining the need for, or the alloca22 tion of, the health resources of the Service. If such an indi23 vidual has been determined to be legally incompetent prior

24 to attaining 19 years of age, such individual shall remain
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1 eligible for such services until 1 year after the date of a

2 determination of competency.

3 ‘‘(b) SPOUSES.—Any spouse of an eligible Indian who

4 is not an Indian, or who is of Indian descent but is not

5 otherwise eligible for the health services provided by the

6 Service, shall be eligible for such health services if all such

7 spouses or spouses who are married to members of each

8 Indian Tribe being served are made eligible, as a class,

9 by an appropriate resolution of the governing body of the

10 Indian Tribe or Tribal Organization providing such serv11 ices. The health needs of persons made eligible under this

12 paragraph shall not be taken into consideration by the

13 Service in determining the need for, or allocation of, its

14 health resources.

15 ‘‘(c) PROVISION OF SERVICES TO OTHER INDIVID16 UALS.—

17 ‘‘(1) IN GENERAL.—The Secretary is authorized

18 to provide health services under this subsection

19 through health programs operated directly by the

20 Service to individuals who reside within the Service

21 Unit and who are not otherwise eligible for such

22 health services if—

23 ‘‘(A) the Indian Tribes served by such

24 Service Unit request such provision of health

25 services to such individuals; and
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1 ‘‘(B) the Secretary and the served Indian

2 Tribes have jointly determined that—

3 ‘‘(i) the provision of such health serv4 ices will not result in a denial or diminu5 tion of health services to eligible Indians;

6 and

7 ‘‘(ii) there is no reasonable alternative

8 health facilities or services, within or with9 out the Service Unit, available to meet the

10 health needs of such individuals.

11 ‘‘(2) ISDEAA PROGRAMS.—In the case of

12 health programs and facilities operated under a con13 tract or compact entered into under the Indian Self14 Determination and Education Assistance Act (25

15 U.S.C. 450 et seq.), the governing body of the In16 dian Tribe or Tribal Organization providing health

17 services under such contract or compact is author18 ized to determine whether health services should be

19 provided under such contract or compact to individ20 uals who are not otherwise eligible for such services

21 under any other subsection of this section or under

22 any other provision of law. In making such deter23 mination, the governing body of the Indian Tribe or

24 Tribal organization shall take into account the con-
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1 siderations described in clauses (i) and (ii) of para2 graph (1)(B).

3 ‘‘(3) PAYMENT FOR SERVICES.—

4 ‘‘(A) IN GENERAL.—Persons receiving

5 health services provided by the Service under of

6 this subsection shall be liable for payment of

7 such health services under a schedule of charges

8 prescribed by the Secretary which, in the judg9 ment of the Secretary, results in reimbursement

10 in an amount not less than the actual cost of

11 providing the health services. Notwithstanding

12 section 404 of this Act or any other provision

13 of law, amounts collected under this subsection,

14 including medicare, medicaid, or SCHIP reim15 bursements under titles XVIII, XIX, and XXI

16 of the Social Security Act, shall be credited to

17 the account of the program providing the serv18 ice and shall be used for the purposes listed in

19 section 401(d)(2) and amounts collected under

20 this subsection shall be available for expendi21 ture within such program.

22 ‘‘(B) INDIGENT PEOPLE.—Health services

23 may be provided by the Secretary through the

24 Service under this subsection to an indigent in25 dividual who would not be otherwise eligible for
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1 such health services but for the provisions of

2 paragraph (1) only if an agreement has been

3 entered into with a State or local government

4 under which the State or local government

5 agrees to reimburse the Service for the expenses

6 incurred by the Service in providing such health

7 services to such indigent individual.

8 ‘‘(4) REVOCATION OF CONSENT FOR SERV9 ICES.—

10 ‘‘(A) SINGLE TRIBE SERVICE AREA.—In

11 the case of a Service Area which serves only 1

12 Indian Tribe, the authority of the Secretary to

13 provide health services under paragraph (1)

14 shall terminate at the end of the fiscal year suc15 ceeding the fiscal year in which the governing

16 body of the Indian Tribe revokes its concur17 rence to the provision of such health services.

18 ‘‘(B) MULTITRIBAL SERVICE AREA.—In

19 the case of a multitribal Service Area, the au20 thority of the Secretary to provide health serv21 ices under paragraph (1) shall terminate at the

22 end of the fiscal year succeeding the fiscal year

23 in which at least 51 percent of the number of

24 Indian Tribes in the Service Area revoke their
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1 concurrence to the provisions of such health

2 services.

3 ‘‘(d) OTHER SERVICES.—The Service may provide

4 health services under this subsection to individuals who

5 are not eligible for health services provided by the Service

6 under any other provision of law in order to—

7 ‘‘(1) achieve stability in a medical emergency;

8 ‘‘(2) prevent the spread of a communicable dis9 ease or otherwise deal with a public health hazard;

10 ‘‘(3) provide care to non-Indian women preg11 nant with an eligible Indian’s child for the duration

12 of the pregnancy through postpartum; or

13 ‘‘(4) provide care to immediate family members

14 of an eligible individual if such care is directly relat15 ed to the treatment of the eligible individual.

16 ‘‘(e) HOSPITAL PRIVILEGES FOR PRACTITIONERS.—

17 Hospital privileges in health facilities operated and main18 tained by the Service or operated under a contract or com19 pact pursuant to the Indian Self-Determination and Edu20 cation Assistance Act (25 U.S.C. 450 et seq.) may be ex21 tended to non-Service health care practitioners who pro22 vide services to individuals described in subsection (a), (b),

23 (c), or (d). Such non-Service health care practitioners

24 may, as part of privileging process, be designated as em25 ployees of the Federal Government for purposes of section
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1 1346(b) and chapter 171 of title 28, United States Code

2 (relating to Federal tort claims) only with respect to acts

3 or omissions which occur in the course of providing serv4 ices to eligible individuals as a part of the conditions under

5 which such hospital privileges are extended.

6 ‘‘(f) ELIGIBLE INDIAN.—For purposes of this sec7 tion, the term ‘eligible Indian’ means any Indian who is

8 eligible for health services provided by the Service without

9 regard to the provisions of this section.

10 ‘‘SEC. 808. REALLOCATION OF BASE RESOURCES.

11 ‘‘(a) REPORT REQUIRED.—Notwithstanding any

12 other provision of law, any allocation of Service funds for

13 a fiscal year that reduces by 5 percent or more from the

14 previous fiscal year the funding for any recurring pro15 gram, project, or activity of a Service Unit may be imple16 mented only after the Secretary has submitted to the

17 President, for inclusion in the report required to be trans18 mitted to Congress under section 801, a report on the pro19 posed change in allocation of funding, including the rea20 sons for the change and its likely effects.

21 ‘‘(b) EXCEPTION.—Subsection (a) shall not apply if

22 the total amount appropriated to the Service for a fiscal

23 year is at least 5 percent less than the amount appro24 priated to the Service for the previous fiscal year.
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1 ‘‘SEC. 809. RESULTS OF DEMONSTRATION PROJECTS.

2 ‘‘The Secretary shall provide for the dissemination to

3 Indian Tribes, Tribal Organizations, and Urban Indian

4 Organizations of the findings and results of demonstration

5 projects conducted under this Act.

6 ‘‘SEC. 810. PROVISION OF SERVICES IN MONTANA.

7 ‘‘(a) CONSISTENT WITH COURT DECISION.—The

8 Secretary, acting through the Service, shall provide serv9 ices and benefits for Indians in Montana in a manner con10 sistent with the decision of the United States Court of Ap11 peals for the Ninth Circuit in McNabb for McNabb v.

12 Bowen, 829 F.2d 787 (9th Cir. 1987).

13 ‘‘(b) CLARIFICATION.—The provisions of subsection

14 (a) shall not be construed to be an expression of the sense

15 of Congress on the application of the decision described

16 in subsection (a) with respect to the provision of services

17 or benefits for Indians living in any State other than Mon18 tana.

19 ‘‘SEC. 811. MORATORIUM.

20 ‘‘During the period of the moratorium imposed on

21 implementation of the final rule published in the Federal

22 Register on September 16, 1987, by the Health Resources

23 and Services Administration of the Public Health Service,

24 relating to eligibility for the health care services of the

25 Indian Health Service, the Indian Health Service shall

26 provide services pursuant to the criteria for eligibility for
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1 such services that were in effect on September 15, 1987,

2 subject to the provisions of sections 806 and 807 until

3 such time as new criteria governing eligibility for services

4 are developed in accordance with section 802.

5 ‘‘SEC. 812. TRIBAL EMPLOYMENT.

6 ‘‘For purposes of section 2(2) of the Act of July 5,

7 1935 (49 Stat. 450, chapter 372), an Indian Tribe or

8 Tribal Organization carrying out a contract or compact

9 pursuant to the Indian Self-Determination and Education

10 Assistance Act (25 U.S.C. 450 et seq.) shall not be consid11 ered an ‘employer’.

12 ‘‘SEC. 813. SEVERABILITY PROVISIONS.

13 ‘‘If any provision of this Act, any amendment made

14 by the Act, or the application of such provision or amend15 ment to any person or circumstances is held to be invalid,

16 the remainder of this Act, the remaining amendments

17 made by this Act, and the application of such provisions

18 to persons or circumstances other than those to which it

19 is held invalid, shall not be affected thereby.

20 ‘‘SEC. 814. ESTABLISHMENT OF NATIONAL BIPARTISAN

21 COMMISSION ON INDIAN HEALTH CARE.

22 ‘‘(a) ESTABLISHMENT.—There is established the Na23 tional Bipartisan Indian Health Care Commission (the

24 ‘Commission’).
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1 ‘‘(b) DUTIES OF COMMISSION.—The duties of the

2 Commission are the following:

3 ‘‘(1) To establish a study committee composed

4 of those members of the Commission appointed by

5 the Director and at least 4 members of Congress

6 from among the members of the Commission, the

7 duties of which shall be the following:

8 ‘‘(A) To the extent necessary to carry out

9 its duties, collect and compile data necessary to

10 understand the extent of Indian needs with re11 gard to the provision of health services, regard12 less of the location of Indians, including holding

13 hearings and soliciting the views of Indians, In14 dian Tribes, Tribal Organizations, and Urban

15 Indian Organizations, which may include au16 thorizing and making funds available for fea17 sibility studies of various models for providing

18 and funding health services for all Indian bene19 ficiaries, including those who live outside of a

20 reservation, temporarily or permanently.

21 ‘‘(B) To make legislative recommendations

22 to the Commission regarding the delivery of

23 Federal health care services to Indians. Such

24 recommendations shall include those related to

25 issues of eligibility, benefits, the range of serv-
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1 ice providers, the cost of such services, financ2 ing such services, and the optimal manner in

3 which to provide such services.

4 ‘‘(C) To determine the effect of the enact5 ment of such recommendations on (i) the exist6 ing system of delivery of health services for In7 dians, and (ii) the sovereign status of Indian

8 Tribes.

9 ‘‘(D) Not later than 12 months after the

10 appointment of all members of the Commission,

11 to submit a written report of its findings and

12 recommendations to the full Commission. The

13 report shall include a statement of the minority

14 and majority position of the Committee and

15 shall be disseminated, at a minimum, to every

16 Indian Tribe, Tribal Organization, and Urban

17 Indian Organization for comment to the Com18 mission.

19 ‘‘(E) To report regularly to the full Com20 mission regarding the findings and rec21 ommendations developed by the study commit22 tee in the course of carrying out its duties

23 under this section.

24 ‘‘(2) To review and analyze the recommenda25 tions of the report of the study committee.
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1 ‘‘(3) To make legislative recommendations to

2 Congress regarding the delivery of Federal health

3 care services to Indians. Such recommendations

4 shall include those related to issues of eligibility,

5 benefits, the range of service providers, the cost of

6 such services, financing such services, and the opti7 mal manner in which to provide such services.

8 ‘‘(4) Not later than 18 months following the

9 date of appointment of all members of the Commis10 sion, submit a written report to Congress regarding

11 the delivery of Federal health care services to Indi12 ans. Such recommendations shall include those relat13 ed to issues of eligibility, benefits, the range of serv14 ice providers, the cost of such services, financing

15 such services, and the optimal manner in which to

16 provide such services.

17 ‘‘(c) MEMBERS.—

18 ‘‘(1) APPOINTMENT.—The Commission shall be

19 composed of 25 members, appointed as follows:

20 ‘‘(A) Ten members of Congress, including

21 3 from the House of Representatives and 2

22 from the Senate, appointed by their respective

23 majority leaders, and 3 from the House of Rep24 resentatives and 2 from the Senate, appointed

25 by their respective minority leaders, and who
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1 shall be members of the standing committees of

2 Congress that consider legislation affecting

3 health care to Indians.

4 ‘‘(B) Twelve persons chosen by the con5 gressional members of the Commission, 1 from

6 each Service Area as currently designated by

7 the Director to be chosen from among 3 nomi8 nees from each Service Area put forward by the

9 Indian Tribes within the area, with due regard

10 being given to the experience and expertise of

11 the nominees in the provision of health care to

12 Indians and to a reasonable representation on

13 the commission of members who are familiar

14 with various health care delivery modes and

15 who represent Indian Tribes of various size

16 populations.

17 ‘‘(C) Three persons appointed by the Di18 rector who are knowledgeable about the provi19 sion of health care to Indians, at least 1 of

20 whom shall be appointed from among 3 nomi21 nees put forward by those programs whose

22 funds are provided in whole or in part by the

23 Service primarily or exclusively for the benefit

24 of Urban Indians.
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1 ‘‘(D) All those persons chosen by the con2 gressional members of the Commission and by

3 the Director shall be members of federally rec4 ognized Indian Tribes.

5 ‘‘(2) CHAIR; VICE CHAIR.—The Chair and Vice

6 Chair of the Commission shall be selected by the

7 congressional members of the Commission.

8 ‘‘(3) TERMS.—The terms of members of the

9 Commission shall be for the life of the Commission.

10 ‘‘(4) DEADLINE FOR APPOINTMENTS.—Con11 gressional members of the Commission shall be ap12 pointed not later than 180 days after the date of en13 actment of the Indian Health Care Improvement Act

14 Amendments of 2005, and the remaining members

15 of the Commission shall be appointed not later than

16 60 days following the appointment of the congres17 sional members.

18 ‘‘(5) VACANCY.—A vacancy in the Commission

19 shall be filled in the manner in which the original

20 appointment was made.

21 ‘‘(d) COMPENSATION.—

22 ‘‘(1) CONGRESSIONAL MEMBERS.—Each con23 gressional member of the Commission shall receive

24 no additional pay, allowances, or benefits by reason

25 of their service on the Commission and shall receive
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1 travel expenses and per diem in lieu of subsistence

2 in accordance with sections 5702 and 5703 of title

3 5, United States Code.

4 ‘‘(2) OTHER MEMBERS.—Remaining members

5 of the Commission, while serving on the business of

6 the Commission (including travel time), shall be en7 titled to receive compensation at the per diem equiv8 alent of the rate provided for level IV of the Execu9 tive Schedule under section 5315 of title 5, United

10 States Code, and while so serving away from home

11 and the member’s regular place of business, a mem12 ber may be allowed travel expenses, as authorized by

13 the Chairman of the Commission. For purpose of

14 pay (other than pay of members of the Commission)

15 and employment benefits, rights, and privileges, all

16 personnel of the Commission shall be treated as if

17 they were employees of the United States Senate.

18 ‘‘(e) MEETINGS.—The Commission shall meet at the

19 call of the Chair.

20 ‘‘(f) QUORUM.—A quorum of the Commission shall

21 consist of not less than 15 members, provided that no less

22 than 6 of the members of Congress who are Commission

23 members are present and no less than 9 of the members

24 who are Indians are present.

25 ‘‘(g) EXECUTIVE DIRECTOR; STAFF; FACILITIES.—
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1 ‘‘(1) APPOINTMENT; PAY.—The Commission

2 shall appoint an executive director of the Commis3 sion. The executive director shall be paid the rate of

4 basic pay for level V of the Executive Schedule.

5 ‘‘(2) STAFF APPOINTMENT.—With the approval

6 of the Commission, the executive director may ap7 point such personnel as the executive director deems

8 appropriate.

9 ‘‘(3) STAFF PAY.—The staff of the Commission

10 shall be appointed without regard to the provisions

11 of title 5, United States Code, governing appoint12 ments in the competitive service, and shall be paid

13 without regard to the provisions of chapter 51 and

14 subchapter III of chapter 53 of such title (relating

15 to classification and General Schedule pay rates).

16 ‘‘(4) TEMPORARY SERVICES.—With the ap17 proval of the Commission, the executive director may

18 procure temporary and intermittent services under

19 section 3109(b) of title 5, United States Code.

20 ‘‘(5) FACILITIES.—The Administrator of Gen21 eral Services shall locate suitable office space for the

22 operation of the Commission. The facilities shall

23 serve as the headquarters of the Commission and

24 shall include all necessary equipment and incidentals
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1 required for the proper functioning of the Commis2 sion.

3 ‘‘(h) HEARINGS.—(1) For the purpose of carrying

4 out its duties, the Commission may hold such hearings

5 and undertake such other activities as the Commission de6 termines to be necessary to carry out its duties, provided

7 that at least 6 regional hearings are held in different areas

8 of the United States in which large numbers of Indians

9 are present. Such hearings are to be held to solicit the

10 views of Indians regarding the delivery of health care serv11 ices to them. To constitute a hearing under this sub12 section, at least 5 members of the Commission, including

13 at least 1 member of Congress, must be present. Hearings

14 held by the study committee established in this section

15 may count toward the number of regional hearings re16 quired by this subsection.

17 ‘‘(2) Upon request of the Commission, the Comptrol18 ler General shall conduct such studies or investigations as

19 the Commission determines to be necessary to carry out

20 its duties.

21 ‘‘(3)(A) The Director of the Congressional Budget

22 Office or the Chief Actuary of the Centers for Medicare

23 & Medicaid Services, or both, shall provide to the Commis24 sion, upon the request of the Commission, such cost esti-
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1 mates as the Commission determines to be necessary to

2 carry out its duties.

3 ‘‘(B) The Commission shall reimburse the Director

4 of the Congressional Budget Office for expenses relating

5 to the employment in the office of the Director of such

6 additional staff as may be necessary for the Director to

7 comply with requests by the Commission under subpara8 graph (A).

9 ‘‘(4) Upon the request of the Commission, the head

10 of any Federal agency is authorized to detail, without re11 imbursement, any of the personnel of such agency to the

12 Commission to assist the Commission in carrying out its

13 duties. Any such detail shall not interrupt or otherwise

14 affect the civil service status or privileges of the Federal

15 employee.

16 ‘‘(5) Upon the request of the Commission, the head

17 of a Federal agency shall provide such technical assistance

18 to the Commission as the Commission determines to be

19 necessary to carry out its duties.

20 ‘‘(6) The Commission may use the United States

21 mails in the same manner and under the same conditions

22 as Federal agencies and shall, for purposes of the frank,

23 be considered a commission of Congress as described in

24 section 3215 of title 39, United States Code.
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1 ‘‘(7) The Commission may secure directly from any

2 Federal agency information necessary to enable it to carry

3 out its duties, if the information may be disclosed under

4 section 552 of title 4, United States Code. Upon request

5 of the Chairman of the Commission, the head of such

6 agency shall furnish such information to the Commission.

7 ‘‘(8) Upon the request of the Commission, the Ad8 ministrator of General Services shall provide to the Com9 mission on a reimbursable basis such administrative sup10 port services as the Commission may request.

11 ‘‘(9) For purposes of costs relating to printing and

12 binding, including the cost of personnel detailed from the

13 Government Printing Office, the Commission shall be

14 deemed to be a committee of Congress.

15 ‘‘(i) AUTHORIZATION OF APPROPRIATIONS.—There is

16 authorized to be appropriated $4,000,000 to carry out the

17 provisions of this section, which sum shall not be deducted

18 from or affect any other appropriation for health care for

19 Indian persons.

20 ‘‘(j) FACA.—The Federal Advisory Committee Act

21 (5 U.S.C. App.) shall not apply to the Commission.

22 ‘‘SEC. 815. APPROPRIATIONS; AVAILABILITY.

23 ‘‘Any new spending authority (described in subsection

24 (c)(2)(A) or (B) of section 401 of the Congressional Budg25 et Act of 1974) which is provided under this Act shall
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1 be effective for any fiscal year only to such extent or in

2 such amounts as are provided in appropriation Acts.

3 ‘‘SEC. 816. AUTHORIZATION OF APPROPRIATIONS.

4 ‘‘(a) IN GENERAL.—There are authorized to be ap5 propriated such sums as may be necessary for each fiscal

6 year through fiscal year 2015 to carry out this title.’’.

7 (b) RATE OF PAY.—

8 (1) POSITIONS AT LEVEL IV.—Section 5315 of

9 title 5, United States Code, is amended by striking

10 ‘‘Assistant Secretaries of Health and Human Serv11 ices (6).’’ and inserting ‘‘Assistant Secretaries of

12 Health and Human Services (7)’’.

13 (2) POSITIONS AT LEVEL V.—Section 5316 of

14 title 5, United States Code, is amended by striking

15 ‘‘Director, Indian Health Service, Department of

16 Health and Human Services’’.

17 (c) AMENDMENTS TO OTHER PROVISIONS OF LAW.—

18 (1) Section 3307(b)(1)(C) of the Children’s

19 Health Act of 2000 (25 U.S.C. 1671 note; Public

20 Law 106–310) is amended by striking ‘‘Director of

21 the Indian Health Service’’ and inserting ‘‘Assistant

22 Secretary for Indian Health’’.

23 (2) The Indian Lands Open Dump Cleanup Act

24 of 1994 is amended—

25 (A) in section 3 (25 U.S.C. 3902)—
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1 (i) by striking paragraph (2);

2 (ii) by redesignating paragraphs (1),

3 (3), (4), (5), and (6) as paragraphs (4),

4 (5), (2), (6), and (1), respectively, and

5 moving those paragraphs so as to appear

6 in numerical order; and

7 (iii) by inserting before paragraph (4)

8 (as redesignated by subclause (II)) the fol9 lowing:

10 ‘‘(3) ASSISTANT SECRETARY.—The term ‘As11 sistant Secretary’ means the Assistant Secretary for

12 Indian Health.’’;

13 (B) in section 5 (25 U.S.C. 3904), by

14 striking the section heading and inserting the

15 following:

16 ‘‘SEC. 5. AUTHORITY OF ASSISTANT SECRETARY FOR IN17 DIAN HEALTH.’’;

18 (C) in section 6(a) (25 U.S.C. 3905(a)), in

19 the subsection heading, by striking ‘‘DIREC20 TOR’’ and inserting ‘‘ASSISTANT SECRETARY’’;

21 (D) in section 9(a) (25 U.S.C. 3908(a)), in

22 the subsection heading, by striking ‘‘DIREC23 TOR’’ and inserting ‘‘ASSISTANT SECRETARY’’;

24 and
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1 (E) by striking ‘‘Director’’ each place it

2 appears and inserting ‘‘Assistant Secretary’’.

3 (3) Section 5504(d)(2) of the Augustus F.

4 Hawkins-Robert T. Stafford Elementary and Sec5 ondary School Improvement Amendments of 1988

6 (25 U.S.C. 2001 note; Public Law 100–297) is

7 amended by striking ‘‘Director of the Indian Health

8 Service’’ and inserting ‘‘Assistant Secretary for In9 dian Health’’.

10 (4) Section 203(a)(1) of the Rehabilitation Act

11 of 1973 (29 U.S.C. 763(a)(1)) is amended by strik12 ing ‘‘Director of the Indian Health Service’’ and in13 serting ‘‘Assistant Secretary for Indian Health’’.

14 (5) Subsections (b) and (e) of section 518 of

15 the Federal Water Pollution Control Act (33 U.S.C.

16 1377) are amended by striking ‘‘Director of the In17 dian Health Service’’ each place it appears and in18 serting ‘‘Assistant Secretary for Indian Health’’.

19 (6) Section 317M(b) of the Public Health Serv20 ice Act (42 U.S.C. 247b–14(b)) is amended—

21 (A) by striking ‘‘Director of the Indian

22 Health Service’’ each place it appears and in23 serting ‘‘Assistant Secretary for Indian

24 Health’’; and
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1 (B) in paragraph (2)(A), by striking ‘‘the

2 Directors referred to in such paragraph’’ and

3 inserting ‘‘the Director of the Centers for Dis4 ease Control and Prevention and the Assistant

5 Secretary for Indian Health’’.

6 (7) Section 417C(b) of the Public Health Serv7 ice Act (42 U.S.C. 285–9(b)) is amended by striking

8 ‘‘Director of the Indian Health Service’’ and insert9 ing ‘‘Assistant Secretary for Indian Health’’.

10 (8) Section 1452(i) of the Safe Drinking Water

11 Act (42 U.S.C. 300j–12(i)) is amended by striking

12 ‘‘Director of the Indian Health Service’’ each place

13 it appears and inserting ‘‘Assistant Secretary for In14 dian Health’’.

15 (9) Section 803B(d)(1) of the Native American

16 Programs Act of 1974 (42 U.S.C. 2991b–2(d)(1)) is

17 amended in the last sentence by striking ‘‘Director

18 of the Indian Health Service’’ and inserting ‘‘Assist19 ant Secretary for Indian Health’’.

20 (10) Section 203(b) of the Michigan Indian

21 Land Claims Settlement Act (Public Law 105–143;

22 111 Stat. 2666) is amended by striking ‘‘Director of

23 the Indian Health Service’’ and inserting ‘‘Assistant

24 Secretary for Indian Health’’.
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1 SEC. 3. SOBOBA SANITATION FACILITIES.

2 The Act of December 17, 1970 (84 Stat. 1465), is

3 amended by adding at the end the following new section:

4 ‘‘SEC. 9. Nothing in this Act shall preclude the

5 Soboba Band of Mission Indians and the Soboba Indian

6 Reservation from being provided with sanitation facilities

7 and services under the authority of section 7 of the Act

8 of August 5, 1954 (68 Stat. 674), as amended by the Act

9 of July 31, 1959 (73 Stat. 267).’’.

10 SEC. 4. AMENDMENTS TO THE MEDICAID AND STATE CHIL11 DREN’S HEALTH INSURANCE PROGRAMS.

12 (a) EXPANSION OF MEDICAID PAYMENT FOR ALL

13 COVERED SERVICES FURNISHED BY INDIAN HEALTH

14 PROGRAMS.—

15 (1) EXPANSION TO ALL COVERED SERVICES.—

16 Section 1911 of the Social Security Act (42 U.S.C.

17 1396j) is amended—

18 (A) by amending the heading to read as

19 follows:

20 ‘‘INDIAN HEALTH PROGRAMS’’; and

21 (B) by amending subsection (a) to read as

22 follows:

23 ‘‘(a) ELIGIBILITY FOR REIMBURSEMENT FOR MEDI24 CAL ASSISTANCE.—The Indian Health Service and an In25 dian Tribe, Tribal Organization, or an urban Indian Orga26 nization (as such terms are defined in section 4 of the
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1 Indian Health Care Improvement Act) shall be eligible for

2 reimbursement for medical assistance provided under a

3 State plan or under waiver authority with respect to items

4 and services furnished by the Indian Health Service, In5 dian Tribe, Tribal Organization, or Urban Indian Organi6 zation if the furnishing of such services meets all the con7 ditions and requirements which are applicable generally to

8 the furnishing of items and services under this title and

9 under such plan or waiver authority.’’.

10 (2) ELIMINATION OF TEMPORARY DEEMING

11 PROVISION.—Such section is amended by striking

12 subsection (b).

13 (3) REVISION OF AUTHORITY TO ENTER INTO

14 AGREEMENTS.—Subsection (c) of such section is re15 designated as subsection (b) and is amended to read

16 as follows:

17 ‘‘(b) AUTHORITY TO ENTER INTO AGREEMENTS.—

18 The Secretary may enter into an agreement with a State

19 for the purpose of reimbursing the State for medical as20 sistance provided by the Indian Health Service, an Indian

21 Tribe, Tribal Organizations, or an Urban Indian Organi22 zation (as so defined), directly, through referral, or under

23 contracts or other arrangements between the Indian

24 Health Service, an Indian Tribe, Tribal Organization, or

25 an Urban Indian Organization and another health care
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1 provider to Indians who are eligible for medical assistance

2 under the State plan or under waiver authority.’’.

3 (4) REFERENCE CORRECTION.—Subsection (d)

4 of such section is redesignated as subsection (c) and

5 is amended—

6 (A) by striking ‘‘For’’ and inserting ‘‘DI7 RECT BILLING.—For’’; and

8 (B) by striking ‘‘section 405’’ and insert9 ing ‘‘section 401(d)’’.

10 (b) SPECIAL RULES FOR INDIANS, INDIAN HEALTH

11 CARE PROVIDERS, AND INDIAN MANAGED CARE ENTI12 TIES.—

13 (1) IN GENERAL.—Section 1932 of the Social

14 Security Act (42 U.S.C. 1396u–2) is amended by

15 adding at the end the following new subsection:

16 ‘‘(h) SPECIAL RULES FOR INDIANS, INDIAN HEALTH

17 CARE PROVIDERS, AND INDIAN MANAGED CARE ENTI18 TIES.—A State shall comply with the provisions of section

19 413 of the Indian Health Care Improvement Act (relating

20 to the treatment of Indians, Indian health care providers,

21 and Indian managed care entities under a medicaid man22 aged care program).’’.

23 (2) APPLICATION TO SCHIP.—Section

24 2107(e)(1) of the Social Security Act (42 U.S.C.
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•S 1057 IS

1 1397gg(1)) is amended by adding at the end the fol2 lowing:

3 ‘‘(E) Subsections (a)(2)(C) and (h) of sec4 tion 1932.’’.

5 (c) SCHIP TREATMENT OF INDIAN TRIBES, TRIBAL

6 ORGANIZATIONS, AND URBAN INDIAN ORGANIZATIONS.—

7 Section 2105(c) of the Social Security Act (42 U.S.C.

8 1397ee(c)) is amended—

9 (1) in paragraph (2), by adding at the end the

10 following:

11 ‘‘(C) INDIAN HEALTH PROGRAM PAY12 MENTS.—For provisions relating to authorizing

13 use of allotments under this title for payments

14 to Indian Health Programs and Urban Indian

15 Organizations, see section 410 of the Indian

16 Health Care Improvement Act.’’; and

17 (2) in paragraph (6)(B), by inserting ‘‘or by an

18 Indian Tribe, Tribal Organization, or Urban Indian

19 Organization (as such terms are defined in section

20 4 of the Indian Health Care Improvement Act)’’

21 after ‘‘Service’’.
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1 SEC. 5. NATIVE AMERICAN HEALTH AND WELLNESS FOUN2 DATION.

3 (a) IN GENERAL.—The Indian Self-Determination

4 and Education Assistance Act (25 U.S.C. 450 et seq.) is

5 amended by adding at the end the following:

6 ‘‘TITLE VIII—NATIVE AMERICAN

7 HEALTH AND WELLNESS

8 FOUNDATION

9 ‘‘SEC. 801. DEFINITIONS.

10 ‘‘In this title:

11 ‘‘(1) BOARD.—The term ‘Board’ means the

12 Board of Directors of the Foundation.

13 ‘‘(2) COMMITTEE.—The term ‘Committee’

14 means the Committee for the Establishment of Na15 tive American Health and Wellness Foundation es16 tablished under section 802(f).

17 ‘‘(3) FOUNDATION.—The term ‘Foundation’

18 means the Native American Health and Wellness

19 Foundation established under section 802.

20 ‘‘(4) SECRETARY.—The term ‘Secretary’ means

21 the Secretary of Health and Human Services.

22 ‘‘(5) SERVICE.—The term ‘Service’ means the

23 Indian Health Service of the Department of Health

24 and Human Services.
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1 ‘‘SEC. 802. NATIVE AMERICAN HEALTH AND WELLNESS

2 FOUNDATION.

3 ‘‘(a) IN GENERAL.—As soon as practicable after the

4 date of enactment of this title, the Secretary shall estab5 lish, under the laws of the District of Columbia and in

6 accordance with this title, the Native American Health

7 and Wellness Foundation.

8 ‘‘(b) PERPETUAL EXISTENCE.—The Foundation

9 shall have perpetual existence.

10 ‘‘(c) NATURE OF CORPORATION.—The Foundation—

11 ‘‘(1) shall be a charitable and nonprofit feder12 ally chartered corporation; and

13 ‘‘(2) shall not be an agency or instrumentality

14 of the United States.

15 ‘‘(d) PLACE OF INCORPORATION AND DOMICILE.—

16 The Foundation shall be incorporated and domiciled in the

17 District of Columbia.

18 ‘‘(e) DUTIES.—The Foundation shall—

19 ‘‘(1) encourage, accept, and administer private

20 gifts of real and personal property, and any income

21 from or interest in such gifts, for the benefit of, or

22 in support of, the mission of the Service;

23 ‘‘(2) undertake and conduct such other activi24 ties as will further the health and wellness activities

25 and opportunities of Native Americans; and
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•S 1057 IS

1 ‘‘(3) participate with and assist Federal, State,

2 and tribal governments, agencies, entities, and indi3 viduals in undertaking and conducting activities that

4 will further the health and wellness activities and op5 portunities of Native Americans.

6 ‘‘(f) COMMITTEE FOR THE ESTABLISHMENT OF NA7 TIVE AMERICAN HEALTH AND WELLNESS FOUNDA8 TION.—

9 ‘‘(1) IN GENERAL.—The Secretary shall estab10 lish the Committee for the Establishment of Native

11 American Health and Wellness Foundation to assist

12 the Secretary in establishing the Foundation.

13 ‘‘(2) DUTIES.—Not later than 180 days after

14 the date of enactment of this section, the Committee

15 shall—

16 ‘‘(A) carry out such activities as are nec17 essary to incorporate the Foundation under the

18 laws of the District of Columbia, including act19 ing as incorporators of the Foundation;

20 ‘‘(B) ensure that the Foundation qualifies

21 for and maintains the status required to carry

22 out this section, until the Board is established;

23 ‘‘(C) establish the constitution and initial

24 bylaws of the Foundation;
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•S 1057 IS

1 ‘‘(D) provide for the initial operation of

2 the Foundation, including providing for tem3 porary or interim quarters, equipment, and

4 staff; and

5 ‘‘(E) appoint the initial members of the

6 Board in accordance with the constitution and

7 initial bylaws of the Foundation.

8 ‘‘(g) BOARD OF DIRECTORS.—

9 ‘‘(1) IN GENERAL.—The Board of Directors

10 shall be the governing body of the Foundation.

11 ‘‘(2) POWERS.—The Board may exercise, or

12 provide for the exercise of, the powers of the Foun13 dation.

14 ‘‘(3) SELECTION.—

15 ‘‘(A) IN GENERAL.—Subject to subpara16 graph (B), the number of members of the

17 Board, the manner of selection of the members

18 (including the filling of vacancies), and the

19 terms of office of the members shall be as pro20 vided in the constitution and bylaws of the

21 Foundation.

22 ‘‘(B) REQUIREMENTS.—

23 ‘‘(i) NUMBER OF MEMBERS.—The

24 Board shall have at least 11 members, who

25 shall have staggered terms.
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•S 1057 IS

1 ‘‘(ii) INITIAL VOTING MEMBERS.—The

2 initial voting members of the Board—

3 ‘‘(I) shall be appointed by the

4 Committee not later than 180 days

5 after the date on which the Founda6 tion is established; and

7 ‘‘(II) shall have staggered terms.

8 ‘‘(iii) QUALIFICATION.—The members

9 of the Board shall be United States citi10 zens who are knowledgeable or experienced

11 in Native American health care and related

12 matters.

13 ‘‘(C) COMPENSATION.—A member of the

14 Board shall not receive compensation for service

15 as a member, but shall be reimbursed for actual

16 and necessary travel and subsistence expenses

17 incurred in the performance of the duties of the

18 Foundation.

19 ‘‘(h) OFFICERS.—

20 ‘‘(1) IN GENERAL.—The officers of the Founda21 tion shall be—

22 ‘‘(A) a secretary, elected from among the

23 members of the Board; and

24 ‘‘(B) any other officers provided for in the

25 constitution and bylaws of the Foundation.
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1 ‘‘(2) SECRETARY.—The secretary of the Foun2 dation shall serve, at the direction of the Board, as

3 the chief operating officer of the Foundation.

4 ‘‘(3) ELECTION.—The manner of election, term

5 of office, and duties of the officers of the Founda6 tion shall be as provided in the constitution and by7 laws of the Foundation.

8 ‘‘(i) POWERS.—The Foundation—

9 ‘‘(1) shall adopt a constitution and bylaws for

10 the management of the property of the Foundation

11 and the regulation of the affairs of the Foundation;

12 ‘‘(2) may adopt and alter a corporate seal;

13 ‘‘(3) may enter into contracts;

14 ‘‘(4) may acquire (through a gift or otherwise),

15 own, lease, encumber, and transfer real or personal

16 property as necessary or convenient to carry out the

17 purposes of the Foundation;

18 ‘‘(5) may sue and be sued; and

19 ‘‘(6) may perform any other act necessary and

20 proper to carry out the purposes of the Foundation.

21 ‘‘(j) PRINCIPAL OFFICE.—

22 ‘‘(1) IN GENERAL.—The principal office of the

23 Foundation shall be in the District of Columbia.

24 ‘‘(2) ACTIVITIES; OFFICES.—The activities of

25 the Foundation may be conducted, and offices may
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•S 1057 IS

1 be maintained, throughout the United States in ac2 cordance with the constitution and bylaws of the

3 Foundation.

4 ‘‘(k) SERVICE OF PROCESS.—The Foundation shall

5 comply with the law on service of process of each State

6 in which the Foundation is incorporated and of each State

7 in which the Foundation carries on activities.

8 ‘‘(l) LIABILITY OF OFFICERS, EMPLOYEES, AND

9 AGENTS.—

10 ‘‘(1) IN GENERAL.—The Foundation shall be

11 liable for the acts of the officers, employees, and

12 agents of the Foundation acting within the scope of

13 their authority.

14 ‘‘(2) PERSONAL LIABILITY.—A member of the

15 Board shall be personally liable only for gross neg16 ligence in the performance of the duties of the mem17 ber.

18 ‘‘(m) RESTRICTIONS.—

19 ‘‘(1) LIMITATION ON SPENDING.—Beginning

20 with the fiscal year following the first full fiscal year

21 during which the Foundation is in operation, the ad22 ministrative costs of the Foundation shall not exceed

23 10 percent of the sum of—
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•S 1057 IS

1 ‘‘(A) the amounts transferred to the Foun2 dation under subsection (o) during the preced3 ing fiscal year; and

4 ‘‘(B) donations received from private

5 sources during the preceding fiscal year.

6 ‘‘(2) APPOINTMENT AND HIRING.—The ap7 pointment of officers and employees of the Founda8 tion shall be subject to the availability of funds.

9 ‘‘(3) STATUS.—A member of the Board or offi10 cer, employee, or agent of the Foundation shall not

11 by reason of association with the Foundation be con12 sidered to be an officer, employee, or agent of the

13 United States.

14 ‘‘(n) AUDITS.—The Foundation shall comply with

15 section 10101 of title 36, United States Code, as if the

16 Foundation were a corporation under part B of subtitle

17 II of that title.

18 ‘‘(o) FUNDING.—

19 ‘‘(1) AUTHORIZATION OF APPROPRIATIONS.—

20 There is authorized to be appropriated to carry out

21 subsection (e)(1) $500,000 for each fiscal year, as

22 adjusted to reflect changes in the Consumer Price

23 Index for all-urban consumers published by the De24 partment of Labor.
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•S 1057 IS

1 ‘‘(2) TRANSFER OF DONATED FUNDS.—The

2 Secretary shall transfer to the Foundation funds

3 held by the Department of Health and Human Serv4 ices under the Act of August 5, 1954 (42 U.S.C.

5 2001 et seq.), if the transfer or use of the funds is

6 not prohibited by any term under which the funds

7 were donated.

8 ‘‘SEC. 803. ADMINISTRATIVE SERVICES AND SUPPORT.

9 ‘‘(a) PROVISION OF SUPPORT BY SECRETARY.—Sub10 ject to subsection (b), during the 5-year period beginning

11 on the date on which the Foundation is established, the

12 Secretary—

13 ‘‘(1) may provide personnel, facilities, and other

14 administrative support services to the Foundation;

15 ‘‘(2) may provide funds for initial operating

16 costs and to reimburse the travel expenses of the

17 members of the Board; and

18 ‘‘(3) shall require and accept reimbursements

19 from the Foundation for—

20 ‘‘(A) services provided under paragraph

21 (1); and

22 ‘‘(B) funds provided under paragraph (2).

23 ‘‘(b) REIMBURSEMENT.—Reimbursements accepted

24 under subsection (a)(3)—
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•S 1057 IS

1 ‘‘(1) shall be deposited in the Treasury of the

2 United States to the credit of the applicable appro3 priations account; and

4 ‘‘(2) shall be chargeable for the cost of provid5 ing services described in subsection (a)(1) and travel

6 expenses described in subsection (a)(2).

7 ‘‘(c) CONTINUATION OF CERTAIN SERVICES.—The

8 Secretary may continue to provide facilities and necessary

9 support services to the Foundation after the termination

10 of the 5-year period specified in subsection (a) if the facili11 ties and services—

12 ‘‘(1) are available; and

13 ‘‘(2) are provided on reimbursable cost basis.’’.

14 (b) TECHNICAL AMENDMENTS.—The Indian Self-De15 termination and Education Assistance Act is amended—

16 (1) by redesignating title V (as added by sec17 tion 1302 of the American Indian Education Foun18 dation Act of 2000) (25 U.S.C. 458bbb et seq.)) as

19 title VII;

20 (2) by redesignating sections 501, 502, and 503

21 (as added by section 1302 of the American Indian

22 Education Foundation Act of 2000) as sections 701,

23 702, and 703, respectively; and

24 (3) in subsection (a)(2) of section 702 and

25 paragraph (2) of section 703 (as redesignated by
333

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•S 1057 IS

1 paragraph (2)), by striking ‘‘section 501’’ and in2 serting ‘‘section 701’’.

Æ
334

Senator ENZI. Chairman McCain, welcome to our home.

STATEMENT OF HON. JOHN MCCAIN, U.S. SENATOR FROM

ARIZONA, CHAIRMAN, COMMITTEE ON INDIAN AFFAIRS

Senator MCCAIN. Thank you very much, Mr. Chairman. I will

make my statement part of the record and ask unanimous consent

to do so.

I would just like to comment that this act is long overdue. It is

important. I think you, in your opening statement, articulated the

importance of this legislation very well. I am very pleased for Senator Dorgan and I to have the opportunity to work with you and

Senator Kennedy and get this bill done. It is long overdue.

Thank you, Mr. Chairman.

Senator ENZI. Thank you.

[Prepared statement of Senator McCain appears in appendix.]

Senator Dorgan.

STATEMENT OF HON. BYRON L. DORGAN, U.S. SENATOR FROM

NORTH DAKOTA, VICE CHAIRMAN, COMMITTEE ON INDIAN

AFFAIRS

Senator DORGAN. Mr. Chairman, let me just add my thank you,

and ask that my statement be made a part of the record. I have

said often I think we have a bona fide emergency in health care

on Indian reservations, the first Americans. I hope very much that

this hearing is one more stimulus towards finally passing this legislation. We should have done it in the last session of Congress, but

we were unable to get there.

So my hope is, and I believe Senator McCain and I have worked

very hard and appreciate your cooperation to do this. My hope is

that we will get a bill to the President for signature that advances

health care on Indian reservations and with Native Americans.

Thank you very much.

Senator ENZI. Thank you.

Senator Kennedy.

STATEMENT OF HON. EDWARD M. KENNEDY, U.S. SENATOR

FROM MASSACHUSETTS

Senator KENNEDY. Mr. Chairman, I want to first of all join you

in thanking Senator McCain and Senator Dorgan for inviting us to

participate in this program. As we know, they have the primary jurisdiction in terms of where Native Americans are living, and the

enormous health disparities that exist for Native Americans in Indian country.

We know that also there are a number of Native Americans who

are in urban areas. We want to try and make sure, to the extent

that we can, is harmonize whatever we are doing here and in your

committee so it ties on into the excellent legislation which they

have introduced.

I just want to commend them. It has been far too long since the

Senate addressed this issue. We have many health challenges in

this Nation, but the disparity issue is such a compelling one. We

will hear time after time of what is happening out there in Indian

country this afternoon. And that is absolutely intolerable in our

country and in our society.
335

Once in a while we get disparities in urban areas among different kinds of groups, but if we look at the total range of health

disparities, it does not exist in any place in our Nation as it exists

with Native Americans. This cries out for action. It cries out for response.

I just want to thank Senator McCain and Senator Dorgan for

their leadership. This legislation is way, way overdue. I thank you

for having the hearing and giving the spotlight on this. I pledge to

work with you and our colleagues to do what we can so we have

a seamless web in trying to make sure that those whose tradition

comes from Indian land are going to have the kind of health care

needs that they are entitled to in our Nation.

I thank you, and I would like to ask that my full statement be

put in the record.

[Prepared statement of Senator Kennedy appears in appendix.]

Senator ENZI. Without objection, all statements will be in the

record.

I think you can tell from the opening statements that there is a

lot of passion behind this, so let’s get on to the witnesses. Our first

witness is Dr. Charles Grim. Dr. Grim is the director of Indian

Health Service. He is the Assistant Surgeon General and holds the

rank of Rear Admiral in the Commissioned Corps of the Public

Health Service. We thank you for being here, Dr. Grim.

STATEMENT OF DR. CHARLES GRIM, DIRECTOR, INDIAN

HEALTH SERVICE, DEPARTMENT OF HEALTH AND HUMAN

SERVICES, ACCOMPANIED BY ROBERT G. MCSWAIN, DEPUTY

DIRECTOR; GARY HARTZ, DIRECTOR, OFFICE OF ENVIRONMENT HEALTH AND ENGINEERING; AND CRAIG

VANDERWAGEN, M.D., ACTING CHIEF MEDICAL OFFICER

Mr. GRIM. Thank you, Chairman Enzi.

Mr. Chairman and members of the committee, we are very appreciative of this joint hearing that you agreed to hold and we are

very honored to be able to testify before you here today on the important issue of the reauthorization of the Indian Health Care Improvement Act.

My name is Dr. Charles Grim. I am accompanied today by Robert McSwain, my deputy director; Craig Vanderwagen, our acting

chief medical officer; and Gary Hartz, our director for the Office of

Environmental Health and Engineering. I will be giving the opening comments for the Department, but my colleagues are with me

today so that we can respond to your questions.

This month, July 2005, marks the 50th anniversary of the Transfer Act, Public Law 83–568, which officially transferred the Indian

health programs from the Bureau of Indian Affairs [BIA] to the

U.S. Public Health Service, effectively establishing the Indian

Health Service. The Transfer Act provided that all functions, responsibilities, authorities and duties relating to the maintenance

and operation of hospitals and health facilities for Indians and the

conservation of Indian health shall be administered by the Surgeon

General of the United States Public Health Service.

This transfer was significant in that our program was moved to

an executive branch department, then the Department of Health,

Education and Welfare, and now the Department of Health and
336

Human Service. This transfer was more appropriate to the role of

the Federal Government in addressing the health care needs of

American Indians and Alaska Natives. Since the Transfer Act, the

health status of Indians have improved significantly.

Today, we are here to discuss another significant milestone in

the evolution of our Federal Government’s responsibility for the

provision of health services to American Indians and Alaska Natives, the Indian Health Care Improvement Act which was first authorized in 1976. It forms the backbone of the system through

which the Federal health programs serve American Indians and

Alaska Natives and encourage their participation in these and

other programs.

IHS has the responsibility for the delivery of health services to

more than 1.8 million federally recognized American Indians and

Alaska Natives through a system of IHS, tribal and urban Indianoperated facilities in programs based on treaties and judicial decisions and statutes. The mission of the agency is to raise the physical, mental, social, and spiritual health of the American Indian

and Alaska Natives to the highest level in partnership with the

population we serve. Our goal is to assure that comprehensive, culturally appropriate, acceptable personal and public health services

are available and accessible.

Our foundation is to uphold the Federal Government’s responsibility to promote healthy American Indian and Alaska Native

people, communities and cultures, and to honor and protect the inherent sovereign rights of tribes.

The Indian Health Care Improvement Act builds upon the Snyder Act of 1921, which authorized regular appropriations for the relief and distress and conservation of health of American Indians

and Alaska Natives. Like the Snyder Act, the Indian Health Care

Improvement Act authorizes programs that deliver health services

to Indian people, as well as providing additional directives and

guidance.

For example, the Indian Health Care Improvement Act contains

specific authorities addressing recruitment and retention of health

professionals serving Indian communities, the provision of health

services, the construction, replacement and repair of health care facilities, access to health services, and the provision of health services to urban Indian people.

We are here today to discuss the reauthorization of the Indian

Health Care Improvement Act and its impact on programs and

services provided for in current law. S. 1057 proposes to amend

current program authority to assure the highest possible health

status for Indians. Improving access for health care for all eligible

American Indians and Alaska Natives is critical to achieving this

goal and a priority for all those involved in the administration of

this important program.

S. 1057, however, also provides expansions which may negatively

impact access by requiring the secretary to consult, negotiate, develop reports and establish programs and activities beyond the reasonable scope necessary to effectively implement the Indian Health

Care Improvement Act. In S. 1057, between desire to improve access and provisions that potentially compromise access, we hope to

find a means for achieving our common goal.
337

Since enactment of the Indian Health Care Act in 1976, statutory

authority has substantially expanded programs and activities to

keep pace with advances in health care delivery and administration. Federal funding for the Indian Health Care Improvement Act

has contributed billions of dollars to improve the health status of

American Indians and Alaska Natives. Much progress has been

made, particularly in the areas of infant and maternal mortality.

The Department has also reactivated the Intra-departmental

Council on Native American Affairs to provide a consistent HHS

policy when working with more than 560 federally recognized

tribes. This council, which was authorized in the Native American

Programs Act of 1974, gives the IHS Director a highly visible role

within the Department on Indian policy. I serve as the vice chair

of that council.

The Department has also revised our consultation policy recently

through a process which involved tribal leaders. The policy emphasizes the unique government-to-government relationship between

Indian tribes and the Federal Government and assists in improving

services through better communications. Consultation is conducted

at different levels and includes annual budget consultations with

tribes to ensure their participation in this important process. The

annual budget meetings provide tribes with an opportunity to meet

directly with all department agencies and identify their priorities

for upcoming years.

In addition, the Centers for Medicare and Medicaid Services has

established a technical tribal advisory group which was established

to provide tribes a vehicle to communicate concerns and comments

to CMS on Medicare, Medicaid and SCHIP policies impacting their

members. IHS has been vigilant about improving outcomes for Indian children and families with diabetes by increasing education

and physical activity programs aimed at preventing and addressing

the needs of those susceptible or struggling with this potentially

disabling disease.

The Department has not been a passive observer of the health

needs of eligible American Indians and Alaska Natives, yet we recognize the health disparities among this population do exist and

are among some of the highest in the Nation for certain diseases,

as you pointed out. We know that improvements in access to IHS

and other Federal programs and private sector programs will result

in improved health status for Indian people.

We support the provisions that increase the flexibility of the Department to work with tribes and urban Indian programs to increase the availability of health care, including new approaches to

delivering care and to expand the scope of health services available

to American Indians and Alaska Natives. I commend Congress for

including in S. 1057 various changes that respond to the concerns

raised in previous proposals. Some of the changes improve the ability of the Secretary to effectively manage the program.

In the area of behavioral health, title VII of S. 1057, it provides

for the needs of Indian women and youth and expands behavioral

health service to include a much-needed child sexual abuse and

prevention treatment program. The Department supports this effort, but opposes specific requirements in certain sections of this

title, specifically 704, 706 and 711. Essentially, it is a ‘‘shall’’ ver-
338

sus ‘‘may’’ issue that diminishes the flexibility of the secretary in

providing for these important programs in a manner that supports

the local control and priorities of tribes and be able to address their

specific needs.

The Department also opposes a new section 104(a)(2) which proposes to allocate the Indian Health Profession Scholarship Program

funding by formula to the 12 IHS areas. If allocation by formula

is authorized, students will not be given an opportunity to apply

for a scholarships if their area does not receive an adequate allocation and if their desired profession is not considered a priority in

their area, even though there may be great needs nationally for

such professions. We would recommend that this program remain

a national program.

My written testimony includes other specific areas of concern. In

addition, the Department continues to carefully analyze all provisions contained in S. 1057. The department would like to continue

to work with your committees to discuss our concerns with the bill

as drafted.

Based on the work that has occurred between the Department

and congressional committees in the 108th Congress on the predecessor proposal, S. 556, to this current bill S. 1057, I am confident

that we can reach a mutual agreement on a bill that can be acceptable to our parties, including tribes and urban Indians, and raise

their health status in the years to come.

I would be pleased to answer any questions that you may have,

and thank your for having us today.

[Prepared statement of Dr. Grim appears in appendix.]

Senator ENZI. Thank you very much for being here. I will mention that we are going to have some confusion with votes that are

starting at 3 p.m. today, but one of the things that we do by having

people serve on panels, we are hoping that they are also open to

written questions. A lot of times we have written questions anyway

that go into much more detail than would be possible for us to be

able to do in a forum like this.

So we hope that all witnesses will be open to answering written

questions, from all committee members. Our purpose is to build a

record so that we have the capability to write the best bill. I appreciate the testimony you have given.

As you might be aware, I am very interested in expanding health

information technology to all health care providers. We have done

some legislation on that. Could you briefly tell me what kinds of

information technology activities are occurring in the Indian

Health Service? More importantly, are there any barriers to broader implementation of those programs?

Mr. GRIM. The Indian Health Service has had electronic health

records for many, many years. Just this year, we started the implementation of a fully electronic graphical user interface health

record. It has now been rolled out in 24 of our sites. We are in

hopes that by the year fiscal year 2008 or 2009, we will have a

fully electronic health record in all of our programs. We are making

use of the latest technology that there is. We have tele-health programs that are excellent that are in the State of Alaska that tie

all of the community health clinics into some of the regional hub

hospitals. We are looking at the expansion of tele-medicine across
339

our agency in the years ahead. We have it in various sites, but not

others.

So I would say, Senator, that we are I think right on the cutting

edge. We are working with the President’s Health Information

Technology Program. We have representatives that are sitting on

that. I would be happy to answer anything further or more details

that you might about that for the record.

Senator ENZI. I will do some followup questions in writing.

Senator McCain.

Senator MCCAIN. Thank you very much, Dr. Grim.

For the record, you might mention who is accompanying you at

the table.

Mr. GRIM. Okay. I have my deputy director, Robert McSwain;

Gary Hartz, our director for the Office of Environmental Health

and Engineering; and Craig Vanderwagen, our chief medical officer.

Senator MCCAIN. Welcome.

Doctor, we have been around this track a few times before, as

you know.

Mr. GRIM. Yes, sir.

Senator MCCAIN. Last year, you raised several objections. We

tried to accommodate them. A lot of those objections have to do

with flexibility. You want maximum flexibility for the Department

to work on meeting the health care needs of Indian people. I understand that. Most bureaucracies do. But some of the objections you

raised last year and this year seem to reflect an unwillingness to

accord the same flexibility to Indian tribes. We find that not proportional. What is your response?

Mr. GRIM. I would just say that we would continue to work with

the committee if there are specific provisions in the bill where you

think that we are giving up the tribes’ flexibility I would be more

than happy to discuss it.

As I mentioned earlier, we have a very robust consultation policy

within both the Department and the Indian Health Service, and do

not make any major policy or budgeting decisions without consulting tribes. So we would be more than happy to work with the committees on those specific issues.

Senator MCCAIN. One specific issue, you raise objection to the

GAO preparing a comprehensive baseline report on Indian health

facilities that is presently in the bill.

Mr. GRIM. Yes, sir.

Senator MCCAIN. Yet your department has never been able to

provide the tribes or Congress any total information on the number, size or status of the Indian health facilities. If the GAO does

not prepare a comprehensive baseline report, then who does?

Mr. GRIM. The reason that we made those comments, Senator

McCain, is that the agency has been in the process over the course

of the last 11⁄2 years in consulting with tribes on a new priority system for the agency. It will be a more expansive type of priority system than our current one. We are in the final process of that. We

had a tribally driven work group called the Facilities Appropriation

Advisory Board, made up of tribal members across the Nation that

developed a priority system recommendation with waiting and criteria.
340

We sent that out to tribal leaders all across the Nation. We received over 800 comments on that. The group incorporated those

and they are very close to making a recommendation to me. That

will be a much more comprehensive listing than we currently have.

That was the reason we asked that reference to GAO doing that

report be removed. We feel that we are very, very close to implementing that. It has been through tribal consultation.

Senator MCCAIN. How does a GAO baseline report interfere with

any of the things you just said? Are you concerned about needless

expenditure of taxpayer dollars? I do not see how a GAO report

would interfere with any of the good things that you just described.

Mr. GRIM. Our concern, I think, is that it would take additional

time of agency staff. We are almost there. We almost have the

data. We would have to work with GAO I think rather extensively

to get the data transferred over to them into a report, but if that

is the committee’s wish.

Senator MCCAIN. Mr. Chairman, I have several questions I

would like to submit for the record. I thank you, Mr. Chairman.

I thank the witnesses.

Mr. GRIM. Certainly, Senator.

Senator ENZI. Senator Dorgan.

Senator DORGAN. Mr. Chairman, thank you very much.

Dr. Grim, you and I have had plenty of opportunity across the

dais to talk about these issues. I will not ask you again the question, what was your recommendation to the Office of Management

and Budget for funding for the Indian Health Service. Was it substantially different than that which was expressed in the President’s budget to the Congress? I have asked you that a couple of

times and I think you have felt like you have been unable to answer it or unwilling to answer it and would probably get in trouble

if you answered it. Do you still feel that way?

Mr. GRIM. Yes, sir. [Laughter.]

Senator DORGAN. Why don’t we get you in trouble today? [Laughter.]

Let me ask you, at a recent hearing one of the witnesses who testified after you and Dr. Carmona spoke mentioned that the Indian

Health Service is funded at about 40 percent or 45 percent of the

level of need. What is your assessment of that? Almost all of us

would agree that there are in many cases a bona fide emergency

with respect to health care on reservations, so it is funded at something below the level of need. What is your assessment of the statement that it is only at 40 percent or 45 percent?

Mr. GRIM. We have some data on that and we can provide that

for the record, Senator Dorgan.

Senator DORGAN. But do you think it is 50 percent of the level

of need or 75 percent of the level of need? Any notion?

Mr. GRIM. We have data that we update annually on that and

I cannot recall what the exact numbers are right now, but we will

provide that.

Senator DORGAN. Do any of your staff know the answer to that?

It just seems to me like that is a pretty fundamental question.

What is the need out there and how close are we to meeting the

need? I have said before in other venues that we have a trust responsibility for health care for American Indians. We also have re-
341

sponsibility for health care of Federal prisoners, and we spend

about twice as much per capita for Federal prisoners’ health care

as we do for Native Americans’.

So it seems to me just by observation we are something substantially below the level of need. I am trying to determine whether we

have any notion of what that is.

Mr. GRIM. We do have a notion of what that is. I do not know

if it has been updated for the current fiscal year, Senator Dorgan,

but it is somewhere in the nature of 60 percent.

Senator DORGAN. At 60 percent? All right. That would suggest

we are about 40 percent short of fulfilling the need, which is really

a serious, serious omission.

My colleague, Senator McCain, asked the question about the

health care facilities. I believe this year the recommendation is a

cut in health care facilities. I think it is around $70 million, $75

million. I would share his question about why would anybody object

to a GAO baseline report. I understand that you are working on

a priorities list. I also understand from an inquiry I made yesterday that that is about 6 months or 9 months away.

Mr. GRIM. We have done the master health services planning for

that whole process across our regions, but you are probably accurate in an about 6-month timeframe before a final report would be

done. What we still have yet to do is we have told the tribes that

if the recommendations that all came in resulted in a significant

change to either the criteria that we were suggested or the

weighting of the criteria, that we would come back to tribal leadership one more time, show them the formula, talk to them about the

changes that had been made and why those had been made based

on the recommendations from around the Nation. And then if there

was not significant disagreement, we would implement that new

priority system, run all of our health services master plans through

that, and then come up with a comprehensive list.

Senator DORGAN. Yes; there is an urgency to do that and get that

done as quickly as possible. I hope you would not object to the requirement in the bill with respect to the GAO. If it is duplicative,

so be it. Although perhaps by the time that would be implemented,

you would have finished your report.

I think certainly on behalf of those of us who serve on the Committee on Indian Affairs, there is an urgency here to find a way

for us to move this legislation forward. We are very frustrated. We

could not do it last year. We should do it now. I hope that you and

others will play a constructive role in letting us, not letting us, in

cooperating with us to move this legislation sooner rather than

later.

Mr. GRIM. Yes, sir; Senator Dorgan.

Senator DORGAN. Thank you, Mr. Chairman.

Senator ENZI. Thank you.

Senator Murkowski.

Senator MURKOWSKI. Thank you, Mr. Chairman.

Welcome, Dr. Grim. I always appreciate your being here and

hearing from you. Your statement this afternoon does not make

any reference to the Dental Health Aide Therapist Program. We

are going to be hearing a little bit more on the third panel this
342

afternoon. As a dentist and as a public health professional, can you

give your opinion regarding this program?

Mr. GRIM. I have traveled to Alaska numerous times, as you

know.

Senator MURKOWSKI. And we like that.

Mr. GRIM. I am looking forward to coming again sometime soon.

I have traveled with our former secretary to that region. We did

have an opportunity to talk with the tribes about that particular

program the last time we were up there last summer. We felt that

the program had merit, and since then additional views have been

coming forward and additional concerns.

We are continuing to meet with all the parties that are concerned. We have met with the Alaska tribes. We have met with the

American Dental Association. We continue to try to look for a solution to the problems of the high levels of unmet dental care that

occur in the bush in the very rural parts of Alaska. We are committed to working with you and with the tribes there to try to resolve

that issue.

Senator MURKOWSKI. Some of us feel that one way to resolve it

is through this Dental Health Aide Therapist Program. Can you

kind of speak to some of the challenges that IHS has in recruiting

dentists for rural Alaska and to these villages?

Mr. GRIM. Yes; I can, Senator. We currently have about a 24 percent vacancy rate for dentists nationally, IHS-wide. The last statistics that I had seen from the tribes in Alaska showed that in the

outer-lying parts of Alaska that number is getting close to about

50 percent. We are having trouble nationally recruiting dentists

into many of our programs.

So we continue to work with organizations like the American

Dental Association. We work with the U.S. Association of Colleges

of Dentistry to try to do what we can to recruit at locations like

that, but currently we are simply lacking the ability to fill those.

Senator MURKOWSKI. Are you having any success with that recruitment then?

Mr. GRIM. We are able to fill our positions to this level, but we

seem to be at about this level and cannot seem to quite get over

to filling greater than about 75 percent of our dental positions right

now. It has been hovering around that for a couple of years.

Senator MURKOWSKI. So as we look into the future, then, with

meeting the dental health care needs of our Alaska Natives in our

villages, do you see a way that we are going to be able to get

enough dentists out there in rural Alaska to meet the need?

Mr. GRIM. I think it is going to require a long-term concerted effort, but I am always hopeful that we are going to be able to do

that. We continue to have moneys in our scholarship and loan repayment programs that we use to try to train new native students,

and I think we need to continue to try to be very aggressive at recruiting current Alaska Natives who want to get into dental school

and try to encourage them to do that; get them into our scholarship

program and hopefully have them go back home and serve their obligations in their communities, and then continue to stay with their

tribal programs and serve out their professional career.

I do think it is going to be a long-term effort. We are working

with all sorts of individuals, as I said, universities and the Amer-
343

ican Dental Association, among others, to try to jointly work on

that issue for the Indian Health Service.

Senator MURKOWSKI. You have kind of ducked the specific question of how you feel about the Dental Health Aide Therapist Program. What I am hearing you say is you recognize the need. We

have to do something. We must do something and that you are

going to be working with us on that.

Mr. GRIM. Yes; Senator Murkowski.

Senator MURKOWSKI. Thank you, Mr. Chairman.

Senator ENZI. Thank you.

Senator Reed.

Senator REED. Thank you, Mr. Chairman.

Thank you, Dr. Grim.

Let me follow on with Senator Murkowski’s question and broaden it to recruiting other health care professionals. It is not just

dentists you have a problem recruiting. Could you lay out the

shortcomings for recruiting as you see them today?

Mr. GRIM. I can give you some specifics on percentages of where

we are right now in many of the professions. I can supply that for

the record. Really, a lot of what we deal with tracks with what the

Nation as a whole is. There is a nursing shortage, and so we are

facing difficulty recruiting nurses as well. Pharmacy and dentistry

continue to be areas where we have high vacancy rates, too, and

it seems to track with some of the needs in the Nation as a whole.

So not only are we facing the private sector economy trying to

recruit the same types of people. Many times our locations are

rural and isolated and so we have the difficulty of that as well on

top of it. But we do have, as I said, scholarships and loan repayment programs. We have very active recruitment programs for

nursing, medicine, dental, pharmacy, and we are doing the best we

can.

I know the professions themselves are looking at those issues,

too, as they see the numbers of certain types of professions, you

know, more people retiring than are graduating and what it is

going to mean for the country.

Senator REED. Is there more that we can do to assist you in

terms of legislation or appropriations? Is this simply a social problem that is beyond any additional help from us?

Mr. GRIM. I guess if I knew the answer, we might already be

here. Yet we would welcome any help that the committee might be

able to provide us. We are still studying the issues, too, and working with the various professional organizations. We have a large

group of professional organizations we work with on a regular

basis. They are all very, very supportive of our program and try to

help us within their own ranks of their professions, but we still

face those difficulties. Thank you for your support.

Senator REED. Doctor, Senator Dorgan alluded to the budget

shortfalls which your rough estimate is about 40 percent gap between the need and the resources. In high-cost parts of the country

like Rhode Island, where we have the Narragansett Tribe, not only

is this funding insufficient, but the costs are significantly higher.

Is there any attention to these areas? Where there are high costs,

housing costs in the area where the tribe has their tribal lands
344

growing at 100 percent, I am not exaggerating, in the last five

years. It is incredible.

Mr. GRIM. I believe you.

Senator REED. It is hard to just maintain the staff. They have

not had a raise in 5 years. Is there any attention to these specifically high-cost areas?

Mr. GRIM. Well, there are some pay adjustments that staff can

get for living in higher cost areas, but one of the things that we

are trying to do is to recognize it on a formula allocation basis. As

I said, whenever we get any new additional program increases, we

consult with tribes on how that is distributed across the Nation. As

they have joined us in the process and the agency not making those

decisions alone, our formulas for distributing money have become

more and more complex, but more sensitive to issues like that. We

have certain formulas now for types of funds that we give out that

a portion of the funds are given out based on the nearest metropolitan area and the costs in that area. So we are trying to take some

of that into account now as we allocate funds. We will divide a formula into three parts and maybe one-third is devoted to the costs

in an area. So if you live in a higher-cost area, you get more funds

in that component of the formula. So we are trying to do that to

try to address it within the funds that we have.

Senator REED. Thank you very much, Doctor.

Thank you, Mr. Chairman.

Senator ENZI. Thank you.

I would mention that Senator Inouye could just be here briefly

between committee meetings and the vote. He does have a statement to submit and questions that he will want to have submitted,

too. And that is open to members of both committees, as well.

Senator Coburn.

Senator COBURN. Thank you, Senator.

Welcome from one Oklahoman to another. Glad to see you again,

Dr. Grim.

Mr. GRIM. Thank you, Senator. Good to see you.

Senator COBURN. Would you like to have an irreversible dental

procedure done on you by a dental health aide? Would you want

your family to have an irreversible dental procedure done by a dental health aide that has a high school graduation and some foreign

training?

Mr. GRIM. I think if I was in a situation where I was in pain

with a lack of adequately trained dentists, I would be able to do

that.

Senator COBURN. That is my whole point. We are going to give

less quality because we are not meeting our need. I just came

through a campaign and one of the things I was critical of, and I

am critical of, is health care to Native Americans, with six times

the rate for dialysis for Native Americans, six times the rate, which

says we are not doing diabetes right. The question is, the ADA opposes this, but why can’t you work out a deal where they have

locum tenens up there? If they really do not want this to happen,

why won’t they volunteer for service up there? Let’s work a deal.

Let’s have them do the right thing.

You create an environment where we can have dentists who will

volunteer their services for Native Alaskans and solve this problem
345

while we are in a shortfall. I think you will find that they will be

agreeable to that. I think that would solve the problem. But this

idea of not meeting our obligation, meeting it by name, but not in

quality, I think is one of the most critical things we have to do at

the Indian Health Service. That is by no means a reflection on the

people who work there. You have a burden and you do not have

the resources with which to carry out the completion and attack

that burden.

With your electronic medical record, have you instituted best

practices, especially for diabetes?

Mr. GRIM. Yes, sir; we have.

Senator COBURN. And that is being followed? Are you tracking

that to see the better outcomes and lower hemoglobin and A(1)(c)s

and better compliance?

Mr. GRIM. Yes, sir; we have. We have seen a downward trend in

the hemoglobin A(1)(c)s. We are seeing better blood pressure control; better us of the ACE inhibitors. We have an extensive database of almost our entire diabetic patient population, tracking both

clinical indicators. We also with the special diabetes program funds

for Indians that Congress made available for us, we have just recently released the report to Congress that shows a huge increase

in the number of both primary and secondary prevention programs

in Indian Country that were present now, prior to the funds were

not available to the population.

So we are seeing a very positive trend in the care of diabetes. We

have been in the diabetes care business for many years. In fact, the

diabetes grant funds, one of the things we did was put together

with professional experts in the agency and the American Diabetes

Association a series of 11 or 12 best practices that tribes could use

in their grants, depending on what were the particular problems in

their communities, and suggested ways they might assess which of

those they wanted to do. So I think we have done an outstanding

job with the use of the funds that Congress given. Tribes deserve

a lot of credit for that because the vast majority of those funds

went directly to tribes. They have implemented a lot of great programs.

Senator COBURN. I would just note that the Congress refused to

support recently with an amendment that I offered for additional

funding for diabetes prevention. We are going to buy more land,

rather than take care of the Native American obligation that we

have. It was pretty disappointing to me. I think we got 17 votes

in the Senate to fund prevention activities for diabetes, so it might

reflect on the Senate where our priorities are.

Do you ongoing tracking on prevention across the board within

Indian Health Service?

Mr. GRIM. Yes, sir; we do. We have long been an agency and a

health care system that focuses on prevention, not just in the clinic, but also in environmental health arenas as well, and safe water

and sanitation facilities, to make huge improvements.

Senator COBURN. So can you give me a time at which we are

going to see the same type of diabetic control in the Indian population, Native American population, that we see in the rest of the

population in this country?
346

Mr. VANDERWAGEN. Dr. Coburn, I would say right now we are

probably leading the Nation in diabetic treatment, not necessarily

primary prevention, but in secondary prevention through effective

treatment with evidence-based best practices. I would say we have

evidence to support the assertion that we are probably leading the

country right now.

Senator COBURN. So we are going to see a decline in complications, amputations, dialysis?

Mr. VANDERWAGEN. In fact, we have had a 50-percent decline

over the last 5 years in amputations. We are the only sub-population where deaths due to ESRD have declined between 2000 and

2002. I think the Senate, the Congress invested well in putting

that money into that diabetes effort. Now, can we extend it to heart

disease, cancer and other chronic diseases is the real challenge that

I think we are facing in Indian country.

Senator COBURN. Well, best practices is going to help you do

that. This is a great example to help us know how we solve the rest

of the health care problem in this country. It is called prevention.

It is not treatment after the fact. It is prevention. And you all are

to be complimented on the institution of best practices because it

is what it is going to take for us to get out of the health care crisis

that we are in in this country. My hat is off to you. I just want

to see the results coming forward, and then work on the prevention

in terms of diet because that is just as important for not only the

Native American community, but the entire American community.

Mr. GRIM. Our three primary focus areas that we have been

working with tribes around the country on are health promotion,

disease prevention, behavioral health issues, both alcohol, substance abuse and mental health, as well as those behavioral issues

with the lifestyle diseases like diabetes and chronic disease management. We are looking at better models with now that we might

put in place in many of our programs because we do have a huge

burden right now of patients that already have these diseases, but

we are focusing on all three of those areas. Again, we are looking

at some best practice models in chronic disease management that

we will start using in some other disease areas.

Senator COBURN. I can ask this later and ask it formally as part

of the record, do you have tracking on malpractice claims within

the Indian Health Service as relative to outside of the Indian

Health Service? Can you give that data to the Committee so that

we can look at it?

Mr. GRIM. Yes, sir; I believe we can.

Mr. VANDERWAGEN. In brief, it is about 100 cases per year that

come to torts. That rate really is about 50 percent compared to the

private sector.

Senator COBURN. Come to trial or that are filed?

Mr. VANDERWAGEN. That are filed and deemed worthy and are

carried forward. That has been a pretty steady state for about the

last 10 or 15 years, some slight trending up. Most of that is associated with our larger, more complex hospitals, but we would be

happy to give you the full picture.

Senator COBURN. Thank you very much.

Let me just thank you again for your service, and I am proud you

are an Oklahoman.
347

Mr. GRIM. Thank you.

Senator ENZI. Senator Murray.

STATEMENT OF HON. PATTY MURRAY, U.S. SENATOR FROM

WASHINGTON

Senator MURRAY. Mr. Chairman, I know that we have a series

of votes on and another panel to come before us. I will be very

brief.

I just want to really thank you and Senator Enzi for having this

joint hearing. I hope that this allows the members of our Health

Committee to really begin to understand this legislation so we can

move it forward. I think we all understand the severe crisis facing

our tribal communities today and the responsibility that we have

to make sure that we address some of the tremendous disparities

that are out there.

I am very pleased that my friend Ralph Forquera, who is from

the Seattle Indian Health Board, is part of the second panel. I

think he is going to provide us with some really excellent information concerning Native Americans who live in urban areas. I am

pleased that he is here. I am sorry that we are going to be having

votes and I will be missing much of his testimony, but it is very

important for our committee to hear that.

I think when we hear the statistics about the fact that Native

Americans are much more likely to die from specific diseases, 420

percent more likely to die from diabetes, 52 percent more for pneumonia and influenza. It goes on and on. I think we have a responsibility, really, to address that.

So Mr. Chairman, I will not ask a question at this time. I will

submit them for the record. Dr. Grim, if you could respond because

I do know we have a series of votes. I am really pleased that we

are having this hearing and allowing our Committee to begin to

understand this problem and help move it forward.

Thank you very much.

Mr. GRIM. Thank you for your interest.

Senator MCCAIN. Thank you very much, Dr. Grim. You got off

easy today. We had a series of vote. [Laughter.]

Mr. GRIM. Thank you for that, Senator McCain.

Senator MCCAIN. Thank you. We would really like to get down

to some serious negotiations so we can get this thing done as quickly as possible. That is going to require, and I know some of this

is not totally up to you, but some of it going to require some concessions on both sides. We do have another body that has to consider

it as well, who we have been in constant communication with, but

this is almost an abrogation of our responsibilities when we do not

address this much-needed legislation.

So thank you, and thank your colleagues for all you do.

Our next panel is Rachel Joseph. She is the chairperson of the

Lone Pine Paiute Shoshone Reservation in Lone Pine, CA. She is

also the cochair of the National Steering Committee for the Reauthorization of the Indian Health Care Improvement Act.

Mr. Don Kashevaroff is the president of the Seldovia Village

Tribe in Alaska. He is also the president and chairman of the Alaska Native Health Tribal Consortium. We are glad you could travel

this long distance to be with us today.
348

I would also like to send a special welcome to Richard Brannan,

the chairman of the Northern Arapaho Business Council from Fort

Washakie, WY. Thank you very much from Fort Washakie, WY. I

thank you for being here today. I have appreciated all the expertise

on tribal issues that you have provided to us over the years. I know

the committee will appreciate your testimony.

I would also like to introduce Ralph Forquera, the executive director of the Seattle Indian Health Board in Seattle, WA.

Ms. Joseph, it is nice to see you. Please begin.

Ms. JOSEPH. Thank you, Mr. Chairman.

Senator MCCAIN. By the way, my colleagues are voting and they

will be coming back and forth. I want to extend my apologies for

the interference of our parliamentary procedures. Welcome, Ms. Joseph.

STATEMENT OF RACHEL A. JOSEPH, CHAIRPERSON, LONE

PINE PAIUTE SHOSHONE RESERVATION

Ms. JOSEPH. Thank you, Mr. Chairman.

I am here today to present testimony on behalf of the National

Steering Committee for the Reauthorization of the Indian Health

Care Improvement Act, the National Indian Health Board and the

National Congress of American Indians. Thank you for this joint

hearing and providing me the opportunity to testify in support of

S. 1057.

The message of Indian nations across the country is please reauthorize the Indian Health Care Improvement Act this year. This

act enacted in 1976 declared this Nation’s policy to elevate the

health status of our population to the highest possible level. We believe this should be at parity with the general U.S. population.

Nearly 30 years later, we are no where near achieving this goal.

However, S. 1057 would facilitate forward movement.

Health care reality in Indian country compared to the general

population is our people still die due to accidents 204 percent

greater than rest of the population; 650 percent more likely to die

from tuberculosis, a preventable disease; 318 percent more likely to

die from diabetes. The epidemiology center in the Northern Plains

has recently reported that the Northern Plains Indians have the

highest SIDS rate in the world. The Surgeon General reports that

Indian youth are dying at 3.1 times greater than the general population.

Our challenges are escalating, and like so many other programs

in the country we are seeing employee take-backs, reduced hours

of operation, staff reduction and burnout. Resources are limited

and our estimates indicate that the Indian health budget has lost

over $2.46 billion in purchasing power over the last 14 years.

I have testified to this before. Medical inflation has increased

over 200 percent since 1984. Unfortunately for the IHS, the OMB

inflation rate ranges from 1.9 percent to 4 percent a year, when

medical costs inflation is between 6.2 and 18 percent.

Like the private sector, we face ever-increasing costs for pharmaceuticals, equipment and other costs. As raised earlier by the Senator, the per capita expenditures for our patients is approximately

one-half of the per capita expenditures for Medicaid beneficiaries,
349

and the expenditures for a prisoner’s health care is almost double

what is spent on a patient in the IHS system.

In 1999, a national steering committee for the reauthorization

was formed. Consultation was held extensively across the country

to develop consensus recommendations to address our current

needs. Included among those recommendations was the authorization for a comprehensive behavioral health program which reflects

tribal values and emphasizes collaboration among alcohol and substance abuse social services and mental health programs, which

was reflected in title VII of S. 1057. I was quite taken aback when

I heard Dr. Grim express objection to section 11(2)(b). In fact, that

has been a challenge for us in dealing with reauthorization. We

have never seen a finite list of what the objections are.

But if I might briefly talk about what our intent was when we

developed language with 711(2)(b). This is a section dealing with

fetal alcohol disorders. We feel strongly that we need to do everything we can to change the behavior of pregnant women, high-risk

pregnant women, and women that are pregnant with Indian babies, to encourage them not to indulge in alcohol and substance

abuse. That was our intent. We think this is a priority and we

think that the program should do this. We are surprised that there

is an objection to that provision.

Another recommendation is authorizing the elevation of the Assistant Secretary, elevation of the Indian Health Service Director

to an Assistant Secretary appointed by the President with the advice and consent of the Senate.

The deplorable disparities in our health indicators compared to

the general population require us to assert that we need to approach our responsibilities differently. Status quo is not acceptable.

We believe that elevation would be comparable to the administration of the BIA programs by an Assistant Secretary in the Department of the Interior and the Assistant Secretary for Public and Indian Housing in the Department of Housing and Urban Development.

We also recommend authorizing the Entitlement Commission to

study the optimal way that health care should be provided to our

people. Indian tribes strongly believe that through the cession of

400 million acres of land to the United States in exchange for

promises for health care and other services often reflected in treaties, that we secured a de facto contract which entitles us to health

care in perpetuity, based on the moral, legal and historic obligations of the United States. We also believe that we need to be able

to address the long-term health care for the elderly as an option,

rather than more expensive, costly or clinical care.

We believe that these recommendations, many of which are included in S. 1057, are essential to help us modernize our health

care delivery.

In closing, I want you to know that in spite of our deplorable

health conditions, we remain optimistic because our tribal governments and programs are having successes and do so much with so

little. We hope for reauthorization this year. We hope that one day

our young people no longer commit suicide because they will have

hope. We hope that one day we will no longer have to deal with

meth problems and other substance abuse in our communities. We
350

hope that our grandchildren will be healthy. We hope that we can

provide long-term quality health care to elders in the waning years

of their lives.

We hope for all these things because we know that the Creator

has put us here for a purpose and we need your help.

Thank you for this time.

[Prepared statement of Ms. Joseph appears in appendix.]

Senator ENZI. Thank you.

Mr. Kashevaroff?

STATEMENT OF DON KASHEVAROFF, PRESIDENT, SELDOVIA

VILLAGE TRIBE, AND PRESIDENT, ALASKA NATIVE TRIBAL

HEALTH CONSORTIUM

Mr. KASHEVAROFF. Thank you, Mr. Chairman.

My name is Don Kashevaroff. I am appearing here as the chair

of the Tribal Self-Governance Advisory Committee, which has appointed me to the National Steering Committee for the Indian

Health Care Improvement Act. I am from Alaska. I am the president of my very small tribe of 400. I am also the president and

chair of the Alaska Native Tribal Health Consortium, which

through Anchorage and the Alaska Native Medical Center, we comanage that and we serve 130,000 Alaska Natives through the

hospital and water and sewer projects in various other programs

that we have.

Both my small tribe and my very large company practice self-determination and self-governance by assessing the health needs of

our people and redesigning and expanding our programs to improve

the available care.

I have a couple of issues that I want to address with you today.

The first one is home health care. I also have submitted written

testimony. Hopefully, that can be in the record, sir. What we found

at ANMC, we have 150 beds. About one-quarter of the beds we

have are taken up by folks that might or should not be there. If

we were a private sector hospital, they would discharge the people.

We continue to serve them because we have no place to send them.

Many of them need step-down units and various other care that we

do not have in existence.

Home health care is in S. 1057, and we are very supportive of

that staying in there. What we found out, as I have stated already,

Indian Health Service does not have the money we need to provide

the services to Indians. What we have been doing over the past few

years is relying more and more on third party payers. We bill insurance companies, if the Indian happens to have insurance, we

bill the insurance company. Those insurance companies actually

say, well, you only can have a stay in the hospital for a couple of

days and then we will not pay anymore, because they know that

there are cheaper ways of providing health care to people than

staying in a hospital bed. So we are kind of stuck with the hospitals and we do not have all the home health care provisions that

we are looking for. So we are very supportive of that in the bill that

we can expand those services.

We have also found out that our elders, the best care we can give

our elders are close to home. When we make our elders travel, they

come in and they actually encounter a foreign language, they en-
351

counter English, and they have to be with us. They have unknown

areas that they have to live in. They lose track of their families.

They are removed from their family. Many of them just refuse to

come in for care. So by having a home health care-based system

where we are able to get out there and provide the services to them

like the rest of the country has realized, will modernize IHS and

bring us up into where we should be, and be able to provide better

health care at a lower price. So we are very supportive of the home

health care provisions in there, Senator.

I would also like to touch on the Federal Tort Claims Act coverage. I noticed in Dr. Grim’s written testimony that they thought

that there might have been an expansion of FTCA coverage. To the

best of my knowledge looking at the Act, there is no change in

FTCA services to ineligible non-beneficiaries. The language does

not increase any change in it.

What we are faced with with Federal tort claims coverage is that

we provide a service, and if we do not have Federal tort claims coverage, we have to take money out of our contracts support costs or

a direct-service budget to pay for insurance that the government or

IHS did not have to pay for before. So when our tribes take over

programs, we have to have coverage. If we do not have coverage,

we have to pay an insurance provider. The amount is staggering

that we have to take out of our direct services budget.

In ANTHC alone, if we had to provide insurance for everybody,

we would lose about four or five specialty providers. We have very

many specialty docs, and we would have to basically let them go

and take the money and buy insurance. We do not want to be in

a situation where we end up doing that. So I am actually puzzled

a bit by Dr. Grim’s written testimony that the Administration has

these concerns that we are expanding coverage because we just do

not see it, and maybe they can tell us later on where they see those

concerns at.

Real quick, also negotiated rulemaking is in the S. 1057. The

Tribal Self-Government Advisory Committee is very supportive of

negotiated rulemaking. We have found in the past that when we

implemented title V of the ISDEAA that it worked extremely well.

They even gave us awards for how well it worked, that we were

able to get IHS in the room, and the tribes in the room. The tribes

are delivering the health care out there and we are encountering

a lot of things that IHS does not have to encounter. We have the

understanding of how to provide health care out in the country. By

working together, we are both able to understand the rules and put

the rules down on paper so we can work better in the future. It

has helped tremendously, us both having the same common understanding.

I also wanted to mention about the dental health aide therapists.

I know we are going to have a panel on that pretty quick. Alaska

Native Medical Center, which is managed by the Alaska Native

Tribal Health Consortium and by South Central Foundation, we

strongly support dental health aide therapists. Without question,

that is our answer to our crisis that we are having in Alaska. I

grew up in a village that luckily had a dentist come every 6 months

from Anchorage. And it was the same dentist, so he knew me, and

I got decent care.
352

People are concerned that there will not be good care. Well, these

dental health aide therapists are sent out to school on it, and for

2 years they are down getting trained to do what they are going

to do. I personally have had times when dentists maybe did not do

as good a job on me as I wished they would have, and I had to go

in for follow-up care. So I think it really comes down to the individual person whether you are going to get a quality dentist or quality

care or not. We have a huge crisis in bush Alaska. If you go to a

village of 100 or 200 people, you are not going to have a dentist

wanting to live there. Even if you have a volunteer come in once

a year, it is not going to provide the services the folks need.

I personally would love to have a DHAT work on my teeth, just

as I go to a nurse practitioner and a physicians assistant for care.

I have no problem doing that.

Finally, I wanted to mention that the tribes want to have, fundamentally we want to look at S. 1057 and make sure that it does

not regress from anything in current law. There was one instance

that we found in section 403, which is the current law section 206,

where Indian health programs may only bill third-party payers for

reasonable charges as determined by the Secretary. This is a

change. Our concern is by making the Secretary figure out what

the reasonable charges are is going to increase the bureaucracy extensively, as opposed to current practice where we bill under current practice methods.

So I do want to thank you for holding this hearing, Mr. Chairman, and hopefully trying to move this legislation forward. I am

here to answer any questions.

Thank you.

[Prepared statement of Mr. Kashevaroff appears in appendix.]

Senator ENZI. Thank you.

Chairman Brannan.

STATEMENT OF RICHARD BRANNAN, CHAIRMAN, NORTHERN

ARAPAHO BUSINESS COUNCIL

Mr. BRANNAN. Good afternoon, Senator Enzi. Thank you for asking me to come and testify.

I come from the Wind River Reservation, carrying a very heavy

heart because of the suffering, the pain, that children and older

people are going through on our reservation. I want to thank you

personally for asking me to come here, and giving us a voice.

There are many statistics that justify the need for improving

health care on the Wind River Reservation and Indian country in

general. I have listed a number of them in my written statement

and I know you hear them from many others. But what I would

like to do is spend my time here today to try to put a face on the

problem that we are faced with every day on the reservation.

My testimony here today is in honor of Francis Brown, a respected elder and ceremonial leader of the Northern Arapaho

Tribe, and Marcella Hope Yellow Bear, a baby, both of whom died

needlessly because of lack of funding. Both of them suffered terribly before their untimely deaths. Francis had four brain tumors.

He went to IHS for assistance. He was told there was no funding

to help him to get the care he needed. He went home, suffered and

died. Marcella Hope Yellow Bear was 18 months old when she died.
353

Her entire short life was one of torture and pain. According to the

newspaper accounts, she had an open hole through her chin, numerous broken bones, and burns on her body and the bottoms of

her feet. She was found hanging from a coat hook in a closet. The

police found her that way. Physically abused and tortured, her

whole life was nothing but pain.

When I did hear, it was like somebody shooting my heart with

an arrow, and part of my soul died when I heard that. Both of

these could have been prevented. The system and all of us failed

them because of lack of adequate funding. For his entire life,

Francis Brown was one of the cultural and ceremonial leaders and

elders of our tribe. Among his many contributions, he helped preserve the medicine wheel up in the Big Horn National Forest and

other sacred sites. His early loss robbed not only his family, but

our tribe of his culture and ceremonial knowledge.

Marcella was a beautiful and innocent little baby, just so beautiful I cannot describe how pretty she was. She was also the hope

of our future. That is our future, our children. In our tribe, we believe children are sacred and we hold onto them because they are

not tainted by the world and they are a blessing from God. Yet she

was killed by her own parents, both members of our tribe, because

of their addiction to methamphetamine. Those drugs and others,

including alcohol, are the scourge of our reservation in Indian country.

As you can see from these two painful examples, we need funding for both prevention and treatment. I am here today to give my

support to S. 1057, but also to remind you of the need to fully fund

it and to remind you of the trust responsibilities of the United

States to American Indian tribes.

Also, the Almighty gave me a vision where I saw this beautiful,

wonderful white house with a bright picket fence, immaculately

maintained yard, with a swing, a play area full of children. I am

sure people have experienced children full of joy, full of happiness,

smiling, seen them dressed in their Sunday best on Easter Sunday

with their little beautiful socks and dresses and healthy and smiling, and just shrilling with happiness. That is the vision the Almighty gave me of the Northern Arapaho children and our people.

I do know that this committee has the ability to make that vision

come true for the Arapaho people, and I ask for your help. I thank

you for allowing me to testify here today.

[Prepared statement of Mr. Brannan appears in appendix.]

Senator ENZI. Thank you.

Mr. Forquera.

STATEMENT OF RALPH FORQUERA, EXECUTIVE DIRECTOR,

SEATTLE INDIAN HEALTH BOARD

Mr. FORQUERA. Thank you, Mr. Chairman.

My name is Ralph Forquera. I am the executive director for the

Seattle Indian Health Board. I am also the director for the Urban

Indian Health Institute, which is a division of the Seattle Indian

Health Board we created in 2000 to conduct research and perform

epidemiologic studies on the health of urban American Indians.
354

I am an enrolled member of the Juaneno Band of California Indians, which is a State-recognized tribe from the San Juan

Capistrano region of Southern California.

The Seattle Indian Health Board is a private nonprofit community health center established in 1970 as a free clinic in what was

then an old U.S. Public Health Service hospital, so we are celebrating our 35th anniversary this year. We are currently under a contract and hold several grants from the Indian Health Service under

title V of the Indian Health Care Improvement Act. We are one of

34 such nonprofit Indian-controlled corporations located in 41 cities

and 19 States around the country that contract with the Indian

Health Service under title V.

About 20 of the 34 existing programs provide some level of direct

care. The remaining 14 programs provide health education, information, referral assistance and other services designed to improve

access to health care. In addition, urban Indian health organizations play an important cultural role in many cities by offering programs and services that are culturally appropriate and socially acceptable to the wide array of Indian people living in cities. For example in Seattle we serve Indian people from over 150 American

Indian tribes and Alaska Native villages each year.

The role of providing an identifiable and culturally acceptable

place in American cities for Indian people is an often overlooked effect of these programs that in many ways has become an essential

part of the healing process for Indian people who often feel abandoned and isolated in American cities. According to the 2000 census, the majority of Indian people are now living in American cities. Over 70 percent of Americans who self-identify as American Indian alone or mixed race on the census are living in American cities.

The trend toward urbanization has been steady since the 1950’s

when the policy of this Nation was to relocate Indian into cities in

an ill-fated attempt at assimilation. Over 160,000 people were directly affected by the relocation and termination policies. There remains a sizeable number of urban Indians who carry an emotional

scar of this experience with them. As a result, that experience

greatly influences their behaviors and their ability to trust government institutions, including oftentimes our own.

Little is known about the overall health status of urban Indians

across the Nation. While the Urban Indian Health Program has

been a part of the Indian Health Service for nearly 30 years, only

recently have formal efforts to document the health of urban Indians been attempted.

The lack of available data has made it difficult for us to defend

the need for help in addressing the growing health crisis among

urban Indians. However, in March of 2004, the Urban Indian

Health Institute released a first report documenting for the public

the severe health disparities among urban Indians. Using data

from the National Centers for Health Statistics and the 1990 and

2000 U.S. census data, that we know is woefully inadequate for

urban areas, the report still found significantly higher rates of illness and identified multiple known risk factors that likely contributed to these findings.
355

The report brought greater attention to the plight of urban Indians and helped us to begin to build interest in looking at the

health of this population. The report documented for the first time

our anecdotal assertion that urban Indians were experiencing illhealth in disproportionate numbers. Our principal partner in this

work to date is the Indian Health Service, which has now included

us as one of the 10 Indian Health Service-funded regional tribal epidemiology centers, ours being the only one that focuses specifically

on urban Indians and is on a nationwide basis.

Title V, the urban Indian health section of the Indian Health

Care Improvement Act, provides the critical link in recognizing

that Indian country encompasses both reservation and urban communities. The 34 urban Indian health organizations reflect the nature of their local communities. They offer not only services, but a

place of Indian identity that is frequently lacking for Indian people

in American cities. In the broadest sense of healing, finding a place

of belonging and acceptance can have a powerful and positive effect

on the health of Indian people.

Our ability to focus on Indian people and not be encumbered by

the restrictive nature of limiting services to federally recognized

tribal members adds to our capacity to heal wounds also. Title V

is the only authority that specifically defines the health care role

for the Indian Health Service in addressing the needs of urban Indians. For this reason, title V is an essential tool in assuring that

urban Indians are not forgotten as a group of Americans in need

of health improvement.

In the request for my participation in the hearing today, two specific questions were posed to me. The first deals with the extension

of Federal tort claims protection for urban Indian programs. The

second concerns an issue that periodically has been brought to our

attention by the Department of Justice regarding equal protections

provisions of the Constitution and the fact that urban Indians are

not subject to tribal governments with self-governance authority.

With regard to the Federal Tort Claims Act issue, similar protections have been extended to community health centers through the

Public Health Services Act. Those of us who receive funding

through the Bureau of Primary Health Care are already eligible for

FTCA protection. It would seem to me that extending this protection to urban Indian health programs would add minimal risk to

the government. Inclusion could save considerable expense for

those programs who are now purchasing private liability insurance

for support for their work. The resulting savings could be used to

provide needed services.

It should also be noted that the title V program is truly crafted

using the community health centers as a model. So therefore the

extension of the privilege of FTCA for another group of federally

sponsored safety net providers seems a fair and equitable action.

With regard to the Department of Justice’s concern about equal

protection matters, I first need to state that I am not an attorney

nor am I professionally trained in this area. However, it seems to

me that the enactment of title V defined a special class of health

care provider similar to various arrangements made through other

Federal programs like the Federally Qualified Health Center Pro-
356

gram under the Bureau of Primary Health Care and disproportionate share hospital payment structure under CMS and others.

Clearly, the Federal Government has a rational basis for providing funding, tax breaks and other benefits it deems to be in the interest of the Government or society in general. That rational basis

should not allow such distinctions to withstand an equal protections challenge.

In the case of urban Indian health programs, the Congress has

a clear and rational basis for its decision to provide programs, services and funding to urban Indians. After all, it was the ill-conceived

policies of relocation and termination that led to the removal of

large numbers of Indian people from reservations to cities. Congress dealt with Indians as a special class of citizens then, and it

clearly can and should so do as it tries to rationally address the

consequences of those policies.

The structure of the title V program, that of using a nonprofit

Indian-controlled corporate structure, offers the full benefits of the

self-determination principles called for in President Nixon’s special

message to Congress in July 1970 that forms the foundation for today’s Federal Indian policy. Successful urban Indian health organizations in some respects embody the spirit of self-determination.

Our use of IHS funds to leverage our other public-private resources

to extend our capacity to serve urban Indians is exactly what I believe the authors of title V intended.

It is clear that the Congress has the authority and the will to direct programs to address identified and documented health disparities affecting American Indians and Alaska Natives. In these times

of rapid change in the health care system in America, and the

sharp escalation in the cost of health care, the importance of having organizations devoted to assuring access and quality health

care for Indian people makes good public policy. It is fitting, then,

that the Congress continue this policy by reauthorizing Title V.

Thank you for offering me this opportunity to testify. I would be

happy to answer questions.

[Prepared statement of Mr. Forquera appears in appendix.]

Senator MCCAIN. Thank you very much.

Ms. Joseph, what is your response to the Department’s view that

the Intra-departmental Council consultation and Tribal Technical

Advisory Groups are sufficient for Indian policy so that the elevation of the director to an assistant secretary is not necessary?

Ms. JOSEPH. Thank you for the question, Mr. Chairman.

The request or the advocacy for the elevation is not a new issue

for tribes, for one thing. It has been around long before this effort

to reauthorize. We feel the deplorable health conditions of our people warrant us to carry out our responsibilities in a different way,

and maybe elevating the issues to a higher level would be a better

approach. We know that status quo is not acceptable.

We think that it is also consistent with the government-to-government relationship in that it is comparable to the assistant secretary that has oversight of the BIA programs in the Department

of the Interior. There is an assistant secretary for Public and Indian Housing in the Department of Housing and Urban Development.
357

We think an agency that has such large responsibilities for Indian people should be at a level where they can collaborate at a

higher level in the Department; be a member at the table when priorities and policies are addressed; be a player in the decisions that

are made when the Department’s priorities are established; and be

at a level that ensures that other agencies in the Department are

also considering the needs of American Indians and Alaska Natives.

Senator MCCAIN. What is your response to the Department’s

view that we should mandate positions such as the diabetes coordinators within IHS?

Ms. JOSEPH. Mr. Chairman, I thought that was real interesting

a request, to require a mandate when earlier in the testimony

there was an objection to mandates. In particular, that is related

to mandating diabetes coordinators. For the record, I believe all

areas have diabetes coordinators. The one we have in California,

she is wonderful and we like her and she is doing a lot to inspire

us, to prevent and to educate.

But the tribal leaders during this discussion weighed this and

did discuss it. They said, say for instance in five years we have a

major epidemic in our area, and we might want a cardiovascular

disease prevention coordinator or a tuberculosis prevention coordinator. With limited resources, the tribes locally may need to move

resources and have another priority in five years. That was the

wish to have some flexibility for local decisions.

Senator MCCAIN. Thank you.

Mr. Kashevaroff, how would you respond to the views of the

American Dental Association that there is a ‘‘false concern’’ that in

Alaska that is only a choice between no dental care and some dental care, so that dental health aides are necessary?

Mr. KASHEVAROFF. I believe that anybody that wants to come up

to Alaska and go out to the bush, which we call it, will see that

there is basically no access to dental care out there. Village folks

that live there, if they have a toothache, they have a choice of either waiting six months to a year for a dentist from a regional hub

to arrive, or to get on an expensive plane and fly in. That is what

we are faced with.

We do have some dental care. Dr. Grim mentioned that we have

a 50 percent vacancy rate out in the bush in Alaska. That means

we only have one-half the dentists. If Washington, DC only had

one-half the dentists, you would have a lot of lines around here of

people wanting dental care.

So it is compounded in the fact that you live in a village and

there is no way to access dental care than hop on a plane, which

you cannot always do because we get snowed in for weeks at a time

sometimes. And you only have one-half the dentists out there in

the first place. So we have a very big problem, Mr. Chairman.

Senator MCCAIN. You mention in your statement that negotiated

rulemaking was used in the self-governance regulations. What benefits have you seen in the implementation of the regulations? What

is your response to the Department’s concerns that negotiated rulemaking is costly and time-consuming? Were your negotiations costly and time-consuming?
358

Mr. KASHEVAROFF. Mr. Chairman, I was not privy to the budget

of the negotiations. I do not think they are that time-consuming because we actually had a deadline imposed. I know S. 1057 has a

longer deadline imposed. But the little bit of time put up front

saves a lot of time in the end.

By us coming together and working out the issues with the IHS,

the tribes and IHS working out the issues, getting on the same

foothold, understanding the same things, has saved us immensely

right now years later from having tons of lawsuits back and forth

because we cannot agree on what we said. When we are both in

the same room, we negotiated it out and you had negotiations go

where there is give and take, and everybody is satisfied somewhat,

and we were able to achieve that.

As I said earlier, they gave us some kind of awards because we

were so efficient at doing it. I cannot imagine why the Administration is against having negotiated rulemaking after we have been so

successful in the past.

Senator MCCAIN. As has self-governance.

Mr. KASHEVAROFF. Yes.

Senator MCCAIN. Chairman Brannan, in your testimony you

state that addiction to methamphetamine and alcohol are epidemic

on your reservation. What is currently being done to combat the

problem and, in your opinion, will the new comprehensive care behavioral health programs provided in the Act be helpful in any

way?

Mr. BRANNAN. Yes, Chairman; they would be.

Senator MCCAIN. It is epidemic on your reservation?

Mr. BRANNAN. Yes; it is.

Senator MCCAIN. Would you give me a few statistics to describe

that situation?

Mr. BRANNAN. I guess throughout Wyoming it is considered epidemic, even in the State of Wyoming. I do not have the specifics.

Senator MCCAIN. For example, most of your teenagers?

Mr. BRANNAN. What you see is an underlying culture of people,

and we have a number of tribal members coming up and saying,

can you please do something for my family member; they are going

to die, because all they are doing is ingesting poison into their system. There is no place for us to send them. There is no treatment

dollars available for methamphetamine whatsoever. Alcohol is a

significant problem, but methamphetamine is 50 times worse.

Probably their life expectancy is less than 5 years once they take

it for the first time. Typically, they are addicted for life once they

do it, just the first time. There is a significant backlog of patients

that need alcohol treatment alone. In some instances, it takes them

6 months to 9 months just to go to treatment. With an alcoholic,

if they finally identify or I guess understand that they do have a

problem, they confess it, you need to get them to treatment as soon

as possible. It is a constant theme. People are dying from cirrhosis.

Senator MCCAIN. You have a lot of dental problems, I would

think.

Mr. BRANNAN. Oh, yes.

Senator MCCAIN. Because of methamphetamines.

Mr. BRANNAN. Yes, yes. Even without the methamphetamines,

we can only serve 25 percent of our actual need. Our service unit
359

is funded at 51 percent of the level of need funding. Our denial rate

is about three times more than what they approve under a contract

health service budget. We are sending people home that have cancer, saying there is no money for chemotherapy, therefore you have

to die. That is the reality of it.

Senator MCCAIN. Then you must have a problem with teen suicide as well.

Mr. BRANNAN. Yes; we did in the 1980’s, there were over 20-some

young people that killed themselves, one right after another. It is

consistent.

Senator MCCAIN. Is that associated quite often with the use of

meth?

Mr. BRANNAN. No; it is mainly associated with the lack of hope

on the reservation, lack of opportunity. What we are doing right

now is we are trying to develop a boys and girls club to give them

some type of outlet. But the main thing is prevention on the reservation. Right now, the lack of funding within IHS is so significant we cannot even do prevention. We have to wait until somebody is sick or almost dying because the funding is so inadequate.

What we need is preventive health dollars. We can work with our

children. We can get them to exercise. We can get them to have a

vision for their future, hope. But right now, we do not have that

resource available.

Senator MCCAIN. Mr. Forquera, is your clinic the only urban

clinic doing epidemiologic studies on urban Indians?

Mr. FORQUERA. It is currently, Senator. We actually established

the Urban Indian Health Institute out of frustration on my part.

Nobody was doing work to directly address the issue of urban Indians. Shortly after we established the organization, Dr. Trujillo, who

was then the director of the Indian Health Service, who had had

some experience working in the urban Indian community, helped

to find some resources to help us set up the epidemiology side of

the research element of the program.

We have been struggling since we have had no directed resource

in order to be able to track the health of urban Indians, and the

fact that a lot of our data has to come from local municipalities or

from other institutions that sometimes do and sometimes do not

collect information that is Indian-specific. We have been having to

go and develop those databases in order to be able to do the work

that we are doing. We are in the process of doing that now, and

I think are making progress, but we are also finding tremendous

obstacles because of resource and other problems.

Senator MCCAIN. Many of your patients are in Seattle due to the

policies of relocation and termination. Do you maintain contacts

with the tribes in which these individuals may be members?

Mr. FORQUERA. A large number of our clients are in fact enrolled

members of their tribes. We also see a number of Indian people

who are members of terminated tribes. We see a few Canadian Indians who come down. And then we are also identifying an awful

lot of Indians who were adoptees or children of adoptees or people

that had been displaced from their nativeness not only in the

1950’s, but prior to that.

One of the great advantages of the work that we do and one of

the fun things that we do is helping people re-link themselves up
360

to their nativeness. It is amazing the power of that experience for

the individual and how good that makes us as an institution feel

that we can help people reconnect with their roots and help them.

They then become great supporters of the organization. They get

services from us. They help the community by using their skills as

part of the community. It is a wonderful thing.

Senator MCCAIN. Chairman Brannan, where is the nearest city

or metropolitan area to your tribal lands?

Mr. BRANNAN. Mr. Chairman, we have two cities. One is Lander,

WY. That is approximately 24 miles from Fort Washakie. The other

town is called Riverton, WY.

Senator MCCAIN. Are there problems with drugs and teen suicide

in those non-Indian areas?

Mr. BRANNAN. It is not as prevalent, but the meth problem is

throughout the State, especially within Fremont County where the

reservation is located.

Senator MCCAIN. Are there meth labs on your reservation?

Mr. BRANNAN. Well, a lot of it I believe is foreigners from old

Mexico. They did have a drug bust, and I think they had 250

pounds of methamphetamine.

Senator MCCAIN. That is a lot of doses.

Mr. BRANNAN. Yes; it is.

Senator MCCAIN. Well, it is a national problem, as you know, but

it also seems to be most concentrated in lower-income areas, and

naturally that means Indian country. At least we would see some

benefits from passage of this act, wouldn’t you think?

Mr. BRANNAN. Yes; it would help us significantly.

Senator MCCAIN. I thank the witnesses. I thank you for your patience today. I apologize for this back and forth shuttle as we try

to finish up our voting on the Department of Homeland Security.

I can tell you at least we passed on amendment yesterday that directs funding directly to the Indian tribes, so it does not have to

go through the State and local authorities. So a small benefit.

Thank you for all you do. Thank you for your good work. We look

forward to seeing you again.

This panel is adjourned.

Now, our last panel is Mary Williard, DDS, deputy director of the

Yukon Kuskokwim Health Corporation in Bethel, AK; and Robert

M. Brandjord, DDS, who is the president-elect of the American

Dental Association in Washington, DC.

Dr. Williard, welcome. Maybe out of pure curiosity, where is

Bethel, AK located, in relation to, say, Anchorage?

Ms. WILLIARD. We are about 450 air miles west of Anchorage.

Senator MCCAIN. And the population is?

Ms. WILLIARD. In Bethel itself, about 6,000 to 7,000, depending

on the time of year.

Senator MCCAIN. What is it in January? [Laughter.]

Ms. WILLIARD. Probably around 6,000.

Senator MCCAIN. And in August?

Ms. WILLIARD. More like 7,000.

Senator MCCAIN. Some come to the great State of Arizona in the

wintertime, and we are always glad to have them.

I thank the Chairman.

Dr. Williard, who is that with you?
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Ms. WILLIARD. This is my daughter. Her name is Suskwok or

Shauna Williard.

Senator MCCAIN. You are welcome to be here. Do you have written testimony? [Laughter.]

Thank you. She is welcome here, Dr. Williard.

Ms. WILLIARD. Thank you.

STATEMENT OF MARY WILLIARD, DDS, YUKON KUSKOKWIM

HEALTH CORPORATION DENTAL CLINIC

Ms. WILLIARD. Mr. Chairman and members of the committee, as

you know, my name is Dr. Mary Williard. I have been practicing

public health dentistry for my entire career. About 9 years of that

has been in the Public Health Service through the IHS. I completed

a 2-year dental residency in general practice at a hospital in North

Carolina. I have practiced both in the Navajo area as well as in the

Bethel, AK area.

I have been in Alaska for 7 years working for the Yukon

Kuskokwim Health Corporation [YKHC]. I have also chaired the

Academic Review Committee for the Dental Health Aide Program

since its inception.

On behalf of the Alaska Native Health Board and YKHC, I would

like to say it is an honor to be here and have the opportunity to

testify, and to bring my daughter to see how this great country

runs.

I really think this is a very important hearing for the future of

the people in my area and especially for the children. I learned this

morning that the ADA has started a campaign in our village newspapers that states that we are providing substandard care, secondtier of care to our village people through the Dental Health Air

Program, specifically dental therapists; that we are experimenting

on the people of the villages. I am here to say very strongly and

clearly that that is not true.

I personally have a vested interest to make sure that that is not

happening. I believe that what we are doing is a good thing and

it has been well thought out. I know that the tribes and the people

in the area are supportive of us.

I am a little nervous so I might stutter a little. Anyway, one of

the things that I have done as part of my role in the Dental Health

Aide Program is help to develop the dental standards that dictate

how we work with the dental health aides and specifically the dental therapists, and how they become certified to provide the care

that they are allowed to do. The quality assessments that are being

one on our dental therapists are taken directly from the Indian

Health Service for dentists. We are not allowing them to provide

a second-tier or a substandard quality of care. They are expected

to provide the services that they provide at the same level of quality.

These candidates have been hand-selected from large numbers of

applicants. They are very responsible, respectable members of the

community. I feel like we have gotten some really wonderful people

into our programs. Part of my job at YKHC is to supervise the dental therapists that we have there. We do have two dental therapists who have completed the 2-year training in New Zealand to receive their diploma of dental therapy. These two young people are
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Alaska Natives and have been in our clinic for about 6 years now

providing services. I have looked at every aspect of their service

and their skills. I have found them to be quite skilled at what they

are doing. They learned well during their schooling. They have

taught our dentist, actually, some new materials and information

that they learned in school.

One of the other things that I do during my time in YKHC is I

have observed the new dentists coming in from dental school. I

have to work with them and bring them up to par with the other

dentist on our staff. What I can say is comparing dental school

graduates with our dental therapists is that I have seen that the

skills are equal.

Hearing Dr. Grim say, sort of hesitate whether he would let a

dental therapist work on his own teeth or his own children, I am

not surprised. Most dentists are very picky about where they go.

I do not know that I would Dr. Grim work on my teeth. I have

never seen what he can do. [Laughter.]

But I can tell you that my children and I have been treated by

the therapists, and I have no problem with that because I have

seen what they can do and I believe that they are very well

trained. They provide a good service.

I look forward to allowing them to go out to the villages once

they are certified and working in a general supervision capacity

with the dentist in Bethel. One of the things that I really think is

important about this is that we will have very competent dental

providers in the villages with the people on a daily basis, so that

not only will the people out there be able to see a dentist maybe

once a year, but they will actually be able to see one when they

need one, a dental provider.

They will be able to see the therapist at the school, at the basketball games, mostly, in the villages, and be able to talk to them in

the grocery store and say, you know, gee, I know you told me I

need to brush my teeth all the time, but what can I do when I cannot afford a toothbrush? And maybe when they are deciding what

to purchase at the store, they can, you know, what were you saying

about the diet soda compared to the regular soda?

Those kind of things are really important when you are talking

about trying to change a community’s habits about oral health.

Daily presence is a much more effective way of changing habits in

a population than the itinerant-type approach that has been utilized in the past. So I think that is a very strong aspect of our program.

I do not think volunteer programs will work. I am not saying

that I do not want to see volunteers come. Please come. Please do

as much volunteer work as you can. I think that would be great.

I do think that they do not provide the continuity of care that will

address the issues that we need and to help build a strong prevention program.

The drill-and-fill model is still the old volunteer model as well.

When you come in and you see patients, you drill and fill and you

just get back out, and you have not made that connection with the

patient. It just has not worked.

One of the things that I have seen as well is that village residents have long, 30 years there have been community health aides
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in the villages. And when a doctor comes out to the village and

talks to the patients and tells them what they know, the patients

will listen, but when the doctor leaves the room, the patient turns

around and asks the community health aide, you know, is that

right? What can you tell me? So the trust is there when the people

are there in the communities.

One of the things about the Dental Health Aide Program is that

the main focus is that we are looking at prevention. However, the

dental health aide therapists are going to be there to help us deal

with the problems that are already existing. You have already

heard there is a very large problem with dental decay in our areas,

unmet needs. Even if Dr. Grim was able to recruit dentists to our

area to fill all the available positions, that is not going to meet our

dental needs. A study in 1991 was done in Alaska that showed that

even if the number of dentists in Alaska was doubled at that time,

it would still take 10 years to meet the needs.

So recruiting dentists to fill positions is not the only answer. We

need all the help we can get. That does not mean we are looking

for substandard care. That means we are looking for good quality

care and we have come up with a method to do that. The dental

health aides or dental therapists have been working in a number

of countries for years and have a very good track record. In Canada, over 30 years of practicing; in Saskatchewan, being regulated

by the dental profession, there has never been any merited claim

against a dental therapist, and they provide the same level of services and more than we will allow under our Dental Health Aide

Program.

So in closing, well, one other thing I would like to say is that we

do thank Dr. Grim for his letter of support of our program, and we

will have that in our written testimony. We also have e-mails of

written support from the South Central Foundation in Anchorage

that states that they strongly endorse the Alaska Dental Health

Aide Therapy Program.

What I would like to ask you all, Mr. Chairman and the members of these committees is to please listen to the people that live

and work in these communities and refuse to take away our federally recognized right to manage our own health care. Please support S. 1057 of the Indian Health Care Improvement Act, and do

not limit the scope of practice of the dental health aides.

Thank you. I am open to questions.

[Prepared statement of Dr. Williard appears in appendix.]

Senator ENZI. Thank you.

Dr. Brandjord.

STATEMENT OF ROBERT BRANDJORD, DDS, PRESIDENTELECT, AMERICAN DENTAL ASSOCIATION

Mr. BRANDJORD. Thank you, Mr. Chairman and members of the

committee.

I am Bob Brandjord. I am president-elect of the American Dental

Association and a practicing oral surgeon in Minnesota. I am here

to express the American Dental Association’s strong support for

using dental health aides and other innovations in dental care delivery to help reduce the disproportionate burden of dental disease

that many Alaska Natives suffer from today.
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Equally important, I must state the American Dental Association’s unequivocal opposition to experimenting on Alaska Natives

by allowing non-dentists to perform irreversible dental surgical procedures. This is second-class care. It is unsafe. It is unfair. And

most of all, it is unneeded. It is an admission that those who have

been entrusted with the care of these people have essentially given

up on them. Instead of really focusing on preventing disease, the

solution is to extract it. Alaska Natives deserve better. They deserve high-quality, fully trained, licensed dentists to provide the

care.

They can receive that care if we can break down the bureaucratic

obstacles that are preventing it. Decades ago, Alaska Natives were

almost entirely free of dental decay, but the trend has reversed.

Many Alaska Natives now suffer from often severe untreated dental disease. Deterioration is due partially to the transition from the

traditional subsistence diet to processed sugary foods and beverages; partly to the lack of oral health education and proper selfcare; and partly to inadequate access to appropriate dental care.

Alarmed at the declining oral health of its constituents, the Alaska Native Tribal Health Consortium has resorted to the desperate

measure of deploying dental therapists to extract teeth, drill out

cavities, and do pulpotomies, which are like a root canal. With only

18 to 24 months of post-high school training, these well-intended,

hard-working people do not know what they do not know. They are

not prepared to routinely perform these procedures safely. Dentists

perform thousands of procedures every day with such expertise

that the public views them as routine or simple. But there is no

simple surgical procedure. I know this. I spend a great deal of

every working day removing teeth.

For example, extracting a tooth can lead to serious and in some

cases life-threatening complications. It can lead to chronic and

acute infection, injury to adjacent teeth, gums, and bone, including

fractured or broken jaws, displacement of teeth, parts of teeth, or

foreign objects into the airway, gastrointestinal tract, and sinuses;

even severe life-threatening breathing or airway problems.

Proponents of the dental therapist plan argue that there are only

two choices: Second-class care or no care. This is not true. Our

written testimony includes an alternative model that builds on the

current dental delivery system by making it more efficient. The authors include the dental director of the Alaska Native Medical Center in Anchorage. Central to this plan is the creation of the new

mid-level aide called a community oral health provider. They can

be trained in Alaska and not in New Zealand. These communitybased dental aides could provide the patient education and preventive services that ultimately are the best and perhaps the only way

to end the epidemic of dental disease that plagues Alaska Natives.

Despite our attempts to help, we have continually run into a bureaucratic brick wall of opposition by those who, by their own admission, are so vested in the therapist position that they will not

consider any alternative.

Mr. Chairman, the public health agencies who took responsibility

for providing care for Alaska Natives have been unable to meet

their own goals. Dentistry did not create this situation, but we are

willing to help remedy it. But therapists are a big step in the
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wrong direction. Rather, we need a dental health aide to provide

education, prevention and appropriate services in every village. We

need a more efficient system to provide the needed care safely and

effectively. We need less redtape.

We urge the Senate to adopt the language offered on the House

side by Chairman Young which supports dental aides, but precludes the use of therapists to perform irreversible dental surgical

procedures.

I want to thank you for your time and attention, and I would be

happy to answer any questions.

[Prepared statement of Dr. Brandjord appears in appendix.]

Senator ENZI. Thank you.

I thank both of the people who testified. The one who is probably

the leading expert among Senators among this would be Senator

Murkowski from Alaska. I will defer to her for questions.

Senator MURKOWSKI. Thank you, Mr. Chairman. I appreciate the

opportunity to lead off with the questions. I unfortunately will have

to be excusing myself after this because I have to get over to the

energy conference, so I am splitting my time.

I do not know. I am not the resident Senate expert because I

spend a lot of time in the dental chair, but I do spend a lot of time

traveling around my State and do know that in terms of health

care issues and the area where we are so lacking is in dental

health care. Dr. Williard, I appreciate your bringing your daughter

here. As a mom with kids that are spending a lot of time in the

dental chair nowadays, it is at this age where we are able to make

a difference with our kids.

Unfortunately, our Native children out in the villages are the

ones that are suffering most. They are suffering because of the

change in diet, as you have indicated Dr. Brandjord, and because

of other changes as we are evolving as a new State, as a society

that is moving from a subsistence lifestyle to a cash economy. It

is hurting out kids’ teeth. As a consequence, it is hurting us as

adult. It is putting a stress and a strain on the whole health care

system.

What is the answer? The answers are very, very difficult. I, for

one, I have a real hardship when people say that we are experimenting on Alaska Natives by providing them with something. We

are not experimenting. We are trying to do something to take that

first step to give the care that is so necessary and is so needed. I

appreciate your testimony, Dr. Williard. I could tell that it was

coming from the heart and very unscripted. You are living there.

You are talking with the people and you know that when you have

a doctor come to town who just blasts in and blasts out, the information that was left with you while you were sitting in that dentist

chair goes out the window with that dentist.

I know because I was raised in a tiny community where the doctor came to town every other week. It was good news for my family

that my mother was not pregnant that year because she did not

have to worry about whether or not she was going to deliver the

baby by herself or whether the doctor was going to be in town. So

we know what happens when we do not have that continuity of

care. There are lapse. There are gaps.
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So we have to do something. We have to do something. The program that we are talking about here today is novel. It is new and

as a consequence it is raising concerns.

I guess I would like to primarily direct my questions to you, Dr.

Brandjord. When the first class of dental health aide therapists

graduated from the University of Otago in New Zealand, the Associate Dean Tom Kardos, who himself is a dentist, said the following. He said:

The dental therapist will be able to provide oral health care, including undertaking procedures such as fillings and extractions, along with educating their communities in good oral health care and habits in accordance with the course they have

taken.

He has been obviously an advocate for the program. He believes

that the dental health aide therapists can safely do the work for

which they have trained.

So I guess my question to you is, what kind of reach-out or conversation or dialogue has the American Dental Association had?

Have you sent any kind of a delegation to New Zealand to meet

with Dr. Kardos, with his colleagues, to observe the level of training that goes on; to attempt to work out some of the differences

that you have indicated that we have with this program?

Mr. BRANDJORD. Thank you, Senator. No, we have not sent anybody to New Zealand, but last year we sent six volunteers from our

government affairs committee up to Alaska to work in the villages.

They went through their normal credentialing process which was

somehow expedited thanks to Indian Health Service. They worked

side by side with Indian Health Service dentists. They were extremely productive and they worked with Alaska Native dental assistants and dental health aides that were there.

Those dental health aides and dental assistants helped them

with the cultural sensitivity and with continuity of care issues that

are brought up. Even in the Indian Health Service, there is a problem with continuity of care with the low number of dentists and

the rapid turnover.

So the dependence on continuity of care comes exactly from the

dental health aides and dental assistants in the area. Dental

health aide therapists doing the procedures are not the answer.

When we looked at the different things, the level of care that had

to be provided, it was very extensive care. If we could look at the

screen up there, you can see one of the patients that was treated

by one of our volunteers. That is not simple work. That is something that is more complex.

If we are going to take care of these individuals, we need fully

trained, licensed dentists to provide that level of care. So that is

what we are talking about. We agree almost completely with everything Dr. Williard was talking about in regards to prevention. Absolutely, prevention is the foundation of all health care. We know

that. Dentistry has done a good job with prevention. We have to

do a good job in Alaska, and that is why we believe that there

should be dental health aides in every Alaskan village to help provide dental preventive services, doing services such as providing

fluorides, sealants, cleanings, and also placing temporary restorations.
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So we really think that is a very valuable resource and we agree

on all of those things. In fact, when you look at our proposal, that

is exactly what it is about. Then we add the community oral health

care provider who coordinates all these efforts among a number of

villages and a population base so that when the dentist comes to

that community, villagers will have continuity of care through the

dental health aide that is there, and dentists can be more efficient

by providing care that is a broad spectrum of care at that time. In

fact our program, when you look at it, uses the Anchorage Hospital

model, and with this efficient system to provide the care, their productivity increased many-fold. In fact, in the last year of implementation, their production increased over 100 percent, and over a 3-

year period of time, over 300 percent.

So we believe that there are four things that we have to do. First

of all, we have to fill up our quotas of Indian Health Care dentists.

The American Dental Association has been to Congress and we

have supported increasing the loan forgiveness payments, which

seems to be a big advantage for getting students out of dental

school going into the Indian Health Service. In fact, when we met

Dr. Grim and one of his assistants, Chris Halliday from Indian

Health Service, he said he believed if he had loan forgiveness for

every slot in the Indian Health Service for dental positions, he

could fill them. So he would need the funding for that. That is one

thing that we want to do.

Second is prevention. I talked about that. Prevention is the foundation for dental care.

Third, are the volunteers. We want to get the volunteers back up

into Alaska.

Senator MURKOWSKI. How do we get them there? We have the

greatest State on Earth and we cannot get professionals to come

out to our villages. We might get them to come out and give us 1

week or 2 weeks on either side of a fishing trip, but we need care

and the care is not just when the fish are running. We have to figure out a way.

Mr. BRANDJORD. It is interesting you say that because our volunteers went up there in the dead of winter. They were not there during fishing season. They understand they are not going up there on

a vacation. They are going to work. We are putting together, and

are now in the process right now of hiring a full-time individual at

the American Dental Association to work with finding volunteers

and setting up the coordination of getting these volunteers into Indian villages and into Alaskan villages. We are trying to get the

care where it is needed.

In fact, when we were putting this together, it is interesting that

we talked to other different health care providers who have volunteer programs. The great State of Alaska is a little different than

some other States because when we talked to the American College

of Obstetricians and Gynecologists, they have a volunteer program

and their members sign up to participate in these programs to go

out specifically through the Indian Health Service. They have given

up on going to Alaska because of the credentialing problems. They

are different than anyplace else.

So one thing that this Committee could do is to bring about a

central certification process that could be used for volunteers to go
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into these areas to help. Our volunteers that went, it has been a

year and a half now, those that went then have to reapply and get

recredentialed now. If they went to one village for one week and

another village for another week, they would have to be

recredentialed. That is inappropriate.

Senator MURKOWSKI. It is.

Mr. BRANDJORD. When we talked to the Joint Commission on Accreditation, of Healthcare Organizations those people say we could

work with a much simpler form where there would be temporary

privileges less paperwork.

Senator MURKOWSKI. We want to work with you on that

credentialing.

Mr. BRANDJORD. We would love to work with you.

Senator MURKOWSKI. From what I understand, we have extended

that offer to kind of work through some of these issues on the

credentialing. To the best of my knowledge, you have not taken us

up on the offer, so we would hope that we would be able to. That

seems like one that we ought to be able to figure through.

Mr. BRANDJORD. I would totally agree with you. It is interesting

that I have a letter here from a dentist in Alaska. If I may read

it, it is very short. It is dated May 25:

On or about February 11 of this year, I submitted an application to participate

in dental project backlog. During the first week of April of this year, I was

fingerprinted as part of the application process. It is now almost June. I understand

there are building transition issues on your part, but what is the status and fate

of my efforts to help alleviate the access issues in the villages?

So yes, we have made that effort, but we are not getting a response on the other side. I do not know how we do that. But if

there is some way to aid us, and when we went out there, we did

not just go out on our own. We went with the Indian Health Service dentists and we worked with them. We believe that that is not

a solution that is going to last forever, but if we can get them over

this backlog of dental disease, we believe we can make a difference.

Senator MURKOWSKI. How many dentists do you think you are

going to be able to or would have to recruit to be able to assist in

this effort, full-time dentists?

Mr. BRANDJORD. For full-time dentists, I do not know. That

would have to be through the Indian Health Service. I am not sure.

But last year at our House of Delegates, which has 360 members,

on 1 day, we handed out a paper, just asking how many would volunteer for a minimum of 2 weeks to go to Alaska. We had 140 volunteers.

Senator MURKOWSKI. Well, I am not meaning to be the negative

nabob here, but one of our big problems is that most of these villages, there is no hotel. There is no bed and breakfast. You are

there and you might sleep at the home of the community health

practitioner or maybe in the gym. It makes it tough on people. So

we have some issues that just make this tough. We need to know

that we have a realistic timeframe that we are dealing with, and

that we are dealing with enough numbers that we can actually

make a difference.

We need to get through this backlog, but we recognize that kids

are born every day, and they are going to have the next generation
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of dental problems. So this is not just something that we can get

on top of the wave now and be clear with.

Mr. Chairman, I am going to have to submit the rest of my questions for the record. I really apologize because this is extremely important. I think you can tell that I want to do something. I hear

that you want to do something. We certainly know that from the

Alaska perspective, those professionals who are giving so much

every day want to make something work.

I do not want to get in a situation where I feel it is the Dental

Association saying this is our turf and nobody else can come onto

it. This is not about turf. This should be about the health and wellbeing of Alaska Native people. If we can put together a program

that provides for continuity of care, that is good and safe and

works, we have the benefits of telemedicine where you can be talking to your real-live doctor in Boston and working on a procedure.

We have made incredible advancements in the State with telemedicine.

I would like to think that we can work through some of these

issues so that we do not have dentists saying there is no other way

except for us to come up, and as Alaskans knowing that Shauna

here is going to be able to see a dentist two weeks out of every

year, and hope that her toothache is during that 2-week time period. So work with us.

Mr. BRANDJORD. We will work with you. We realize the epidemic

of dental disease that is there. We want to do nothing more than

help to resolve that issue. But to resolve that issue, to keep doing

fillings and extractions will not resolve it. What will resolve it is

to have good preventive care. We can accomplish that with the dental health aides.

In regards to your statement about the facilities and the bed and

breakfasts up there, yes, the bed and breakfast for every one of our

volunteers up there was bringing their own sleeping bag and sleeping on the floor of the clinic. So yes, we are familiar with that, but

they are still willing to go back. They are that dedicated. I think

that is something that is hard for people to perceive.

I thank you for your concern.

Senator MURKOWSKI. It is also hard for them to give more than

2 weeks, and that is one of our biggest problems. That dedication,

that passion is there and they will come up and they will give, and

it is extremely generous. We do not want to denigrate that generosity, but there is a recognition that there are 50 other weeks of the

year that are without any kind of care. So we will work on filling

those gaps.

Mr. Chairman, thank you very much.

Senator ENZI. Thank you.

Senator Isakson.

Senator ISAKSON. Thank you, Mr. Chairman.

Yesterday, I had one of those irreversible dental procedures

known as a root canal, so I am having a tough time talking about

this subject. [Laughter.]

Senator ISAKSON. I am honored to be here and appreciate both

your testimonies. I am sorry I was late for the other panels.

Dr. Williard, you are a dentist and I take it you oversee a regional plan. Do you manage the dental health aides?
370

Ms. WILLIARD. Yes; I do.

Senator ISAKSON. I do not want to cut you off, but I want to get

to the end question.

Ms. WILLIARD. Okay.

Senator ISAKSON. And that is a full-time program for the Native

Alaskans.

Ms. WILLIARD. Yes.

Senator ISAKSON. How many dentists and how many dental

health aides are in that program?

Ms. WILLIARD. We have nine dentists in the Bethel area. We

have two dental therapists, and we have nine primary dental

health aides.

Senator ISAKSON. Okay. Here is my question, and I did not get

a chance to read. I take it this S. 1057 has a scope of practice component to it. What new scope of practice are these therapists or

aides going to be allowed to do under this bill that they cannot do

now?

Dr. WILLIARD. There is no new scope of practice that they would

be able to do under S. 1057. What the American Dental Association

would like to see done is to have this bill modified so that it takes

away the rights that we have to practice as we are doing right now.

Senator ISAKSON. Okay. Now, Dr. Brandjord just referred to the

program they had recommended. They have suggested a program

which I take it drew the line on scope of practice for the therapist

and the aides. Is that correct?

Dr. WILLIARD. Yes.

Senator ISAKSON. You said you have nine dentists there in your

program now?

Ms. WILLIARD. Yes.

Senator ISAKSON. Then that is not enough dentists to do the irreversible dental procedures?

Ms. WILLIARD. We have 15 dental positions in our area, so we

have 6 that are vacant right now. As I have said before, filling

those vacancies does not actually provide enough treatment ability

to meet the needs. So even if we were to get 100 percent filling of

those positions, it still would not meet the needs that are out there.

That would just meet the criteria that have been set by what is

able to be funded by the IHS and by our corporation.

Senator ISAKSON. One of the issues that comes up in many

health professions in scope of practice is a shortage of trained people being the justification to allow a scope of practice possibly beyond the training of others. Are we in that position in Alaska now

where we in effect have people who are trying to do the best they

can, but are not sufficiently trained to do, say, root canals, which

I think take a lot of training after yesterday’s experience? I hope

so.

Dr. WILLIARD. You are talking about the dental therapists not

having the training to do that?

Senator ISAKSON. Yes. I am saying, in Alaska are we having to

resort to asking people, with the best of intention, to do procedures

they are not trained for?

Ms. WILLIARD. No; we are not asking them to do procedures they

are not trained for. The dental therapists that we have sent to

training and are training further in our own facilities have a spe-
371

cific scope of practice which limits what they can do in a patient

care setting. That limit will keep them in a practice setting that

utilizes only what their skills are. If a patient’s care needs get beyond the limits that a dental therapist has been trained to provide,

then they are trained to recognize those limits and refer to a dentist.

The picture that you saw earlier from the ADA, definitely I agree

with them. That is beyond the scope of practice of a dental therapist. That patient would be referred to the hub clinics for treatment. But fortunately, that is not the only kind of patient we see.

We do have a lot of patients that need a little less than that severe

care, and can be seen by the therapists and the procedures that

they are capable and competent of performing.

Senator ISAKSON. Okay. Dr. Williard, in the proposal that the

ADA made, what is it that you do not like about their proposal?

Ms. WILLIARD. They have excluded the use of the therapists.

Senator ISAKSON. Totally? Or just for these irreversible procedures?

Ms. WILLIARD. The therapists are distinguished by the fact that

they can do irreversible procedures. What their suggestion would

do for a therapist is strip them of their ability to provide those

services. They would become basically a primary dental health

aide, which is a health aide that we already have and who we can

train for about a month in Bethel to provide the preventive services

and the fluoride treatments that they are providing already.

So basically, it would be the equivalent of tying a dentist’s hand

or arm behind their back and asking them to treat a patient. That

is what their proposal would do. We do not say that their proposal

is not okay, for lack of a better word. I think it is a good proposal

in some settings. I think it would be fine to do that Community

Oral Health Practitioner Program in parallel with the Dental

Health Aide Program. Anything that people are willing to do to try

and help provide more services to our area is a good thing as long

as it is well thought out and supported with data.

What I do not agree with is that the American Dental Association is not willing to allow that to happen at the same time as our

Dental Health Aide Program is running. They want us to drop the

program and then pick up this other program. That will not work.

We have seen and looked at all of the studies that show that the

dental therapist is a safe, quality provider. You can look at Gordon

Trueblood from Canada who has done extensive studies on the

quality of care provided by a dental therapist.

In those studies, he has shown that the quality is equal, if not

better, than a dentist in the procedures that a therapist is allowed

to perform. A therapist does not do a whole scope of dental procedures that a dentist would do. Their training is very heavily geared

towards teaching them what their limits are. This is very different

from what you might learn in dental school, where you are taught

all eight different specialties in the dental field. Nobody tells you

that you cannot do something.

Senator ISAKSON. Mr. Chairman, could I have the liberty of asking two more questions?

Senator ENZI. Certainly.

Senator ISAKSON. I know I have gone beyond my time.
372

I have said this before, and am not taking sides here even

though it is going to sound like I am. The dental profession, of all

the health professions, seems to me to have done a remarkable job

of lessening the volume of work because of what they did in preventive health care, fluoridation of the water, and good health

practices. You, Doctor, and the association are to be credited for

that.

It sounds to me like the exacerbation of the problem in Alaska

over the last 10 years is a whole absence of that, or at least a significant one. Otherwise, it may be the change in eating habits, you

referred to people fluoridating and things like that.

If it has been done once in the continental United States, understanding there is a world of difference in Atlanta, Georgia and

Alaska, and where Native villages might be. I know accessibility is

a problem and everything else. I guess I ought to ask the Doctor

a question for a minute, because I have been directing everything

to you.

Is your proposal designed with that goal in mind? If it is, can the

number of trained professionals be available to meet the demand

that exists today, and even would exist if there were some lessening of those problems?

Mr. BRANDJORD. Thank you for your question. First of all, with

the proposal that has been made, using the community oral health

provider, that particular program, and it has been looked at by

these three people in education and then one who is the director

up at the Anchorage dental facility, they estimate that using that

particular program, 85 percent of the individuals within that village could be seen and taken care of in any year. Now, that is in

the paper that has been submitted along with our written testimony.

One other thing in regard to your comments about the scope of

practice of individuals, part of the issue is that the expanded function dental assistants can help do some of the reversible procedures

and that is why they become more efficient. They will have one

dentist per three or four auxiliaries in the Anchorage facility working in up to three chairs at one time so that they can be more efficient and produce more care, and then deliver also more preventive

services.

So yes, there is an expanded scope that is there that can be done,

and yes they can reach more people.

If I can just add one thing. You mentioned fluoridation. There

are fluoridation units in the villages, but they are not activated

right now. Some of it is the CDC’s requirements for maintenance.

From our understanding now, we have some new technology that

CDC has and that has been implemented in the tribal villages in

South Dakota where they have remote control of the fluoridation

of the water system that can work.

Senator ISAKSON. Well, I have abused my time. CDC is in my

home State and if you all have any problem with them, you let me

know because you need all the help you can get out there.

Your daughter is beautiful, Dr. Williard.

Ms. WILLIARD. Thank you.

Senator ISAKSON. Thank you for the time, Mr. Chairman.

Senator ENZI. Thank you.
373

Ms. WILLIARD. Could I make one comment about the program,

the community oral health aide program?

Senator ENZI. Certainly.

Ms. WILLIARD. Thank you, sir.

The program, it was written by a panel of people who did include

one of the chiefs from the Anchorage area, Tom Kovalesky. In teleconferences and meetings with the authors of that proposal, and

the dental chiefs of Alaska throughout the State, Dr. Kovalesky

and the other officers did concede that this proposal was probably

not as effective in the rural areas and that it would be more effective in an urban setting.

The situation that we find in our individual villages, having to

fly in by airplane and being spread out with such small populations

in some of these communities, the models that are used in that program do not apply. That is something that the dental directors outside of Anchorage unanimously agree with.

Senator ENZI. Thank you.

I want to thank both of you and all of the other people that have

testified. I apologize for the interruptions. We are still doing votes.

Senator McCain and I have been shifting off and on here so that

we would have somebody chairing and could continue to gather the

information. All of this, of course, builds some testimony that will

be used in furthering the legislation, correcting the legislation,

drafting additional legislation.

There will be more statements submitted by other members of

both committees, and questions that I hope all panelists will take

time to answer. You will not all receive questions because we will

be searching for things that are in your area of expertise or clarifications on what you said in your statement or things that you

may have said today.

Also, members of the panel, if you have some comments in regard to other questions that were not asked, or if you want to expand on the comments that were made, you are perfectly able to

do that, too. The record will remain open for another 10 days to

complete that process.

So I appreciate everyone who has helped out here today and the

hearing is adjourned.

[Whereupon, at 4:55 p.m., the committee was adjourned, to reconvene at the call of the Chair.]

(375)

APPENDIX

ADDITIONAL MATERIAL SUBMITTED FOR THE RECORD

PREPARED STATEMENT OF HON. MARIA CANTWELL, U.S. SENATOR FROM WASHINGTON

Thank you, Mr. Chairman. I appreciate your continued leadership on these issues

which we have been working on for a number of years.

I’d also like to thank you for opening this hearing up to our HELP Committee

colleagues. Their expertise in healthcare delivery, will be extremely valuable as we

work together to improve the health and well-being of Native Americans.

I believe reauthorizing the Indian Health Care Improvement Act will help us

begin to close the disturbing health disparity in Indian country and allow us to fulfill the United States’ obligation for Indian health.

According to the U.S. Commission on Civil Rights, between 1998 and 2003, industry experts estimate that medical costs grew approximately 10–12 percent, while the

IHS funding increases are less than 5 percent annually. When compared to other

Federal health expenditures, it’s clear that IHS is grossly under funded. We have

a responsibility to take a close look at the healthcare services we’re providing to this

population and make sure that they’re equitable and adequate.

This issue is particularly important to Washington State. Between 1990–2000, the

Indian population grew almost by almost 28 percent—7.5 percent faster than the

rest of our population. The life expectancy for Indians living in Washington is approximately 4 years shorter than that of the rest of the population, due to factors

that we can impact—chronic under funding of the Indian Health Service, the lack

of geographically available health services and the lack of trained providers that are

available to serve the Indian population. We can address these issues for Washington and the rest of Indian country by moving forward with the reauthorization of

this critical legislation.

To give you an idea of how badly this legislation needs to be updated, I’ll use the

example of behavioral health services. The current law limits behavioral health

services to those dealing with substance abuse. While substance abuse is a critical

health issue, mental health disorders are not addressed. This is particularly alarming when one looks at the suicide rate of the Indian population—91 percent higher

than the rest of the United States. Clearly there is a need for increased attention

to the behavioral health needs of the Indian population.

I’m pleased to see the increased focus on preventative health in this bill. While

Indian country is still experiencing a shorter life expectancy than other American

populations, the causes of death have shifted. Today the leading causes of death

among Indian populations are chronic disease rather than infectious disease, communicable diseases. The health disparities that exist among the Indian population

are numerous and unacceptable. They have higher rates of almost every disease and

adverse health condition:

• Alcoholism—777 percent higher.

• TB—650 percent higher.

• Diabetes—450 percent higher.

• Accidents—208 percent higher.
376

• Pneumonia/influenza—52 percent higher. • Suicide rate—91 percent higher.

Although the health disparities still exist in Washington and across the country,

we have made progress. I am aware, for example, of our success in the Northwest

in reducing the rate of Sudden Infant Death Syndrome, diabetes, HIV/AIDS, cancer

and tobacco use through the use of health promotion and disease prevention programs. Reauthorization would allow for the expansion of facilities construction options, enhance tribal decisionmaking and enhance the ability to recruit, train and

retain health professionals.

The last time this bill was reauthorized was in 1992 and it expired in 2000. Since

then, bills have been proposed every year to no avail. This is a very complicated

issue, it’s a huge bill but the time has come to fully address the health needs of

the Indian population.

We have a legal and ethical responsibility to provide healthcare to Indians and

this is the perfect opportunity to begin to address ways in which we can improve

the way we do so.

One area of great concern to me is the impact of the Medicare Prescription Drug

Benefit implementation on Indian country. The Tribal Technical Advisory Group

was formed to consult with the Center for Medicare & Medicaid Studies (CMS) on

reimbursement rates and policies. Under the roll-out of the transitional assistance

or, the drug discount card, under the Medicare Modernization Act earlier this year,

we saw many problems in the implementation of this program. Beneficiaries were

often confused about their choices and many didn’t know they even had a choice to

make. Like other low-income elders across the country, low-income Indian elders

will experience a gap in prescription drug coverage when their costs exceed the initial $1,500 coverage limit. Most Indians will expect their HIS and Tribal Clinics to

pay for their pharmaceuticals after they fully utilize their prescription drug coverage. However, IHS expenditures will not be counted toward the threshold to qualify for the catastrophic coverage under the drug plan. IHS will have to absorb all

pharmacy costs for Indian elders up to the $3,600 annual limit. I am hopeful that

in consultation with my colleagues on the Senate Finance Committee, we will resolve this inequity.

Another area of grave concern to me is the lack of attention that behavioral

health services in our healthcare delivery system. According to the Indian Health

Service, 13 percent of Indian deaths occur in those younger than 25 years of age—

three times that of other populations and the U.S. Commission on Civil Rights

points out that American Indian youth are twice as likely to commit suicide.

Reauthorization is especially important as it provides an opportunity to address

the need for mental health coverage within the IHS. Title VII proposes a comprehensive approach for behavioral health assessment, treatment and prevention.

Under current law, behavioral health provisions are largely limited to substance

abuse treatment and prevention and the issue of mental health is largely

unaddressed.

The current Indian health bill is a product of much collaboration between tribal

leaders, IHS officials and program personnel and it’s imperative that we look to

these experts during this process.

I’d also like to thank Ralph Forquera, the executive director of the Seattle Indian

Health Board, for joining us here today. Each year, the Seattle Indian Health Board

serves over 6,000 individual patients and provides approximately 30,000 patient encounters. While the Seattle Indian Health Board has become quite skilled at providing high quality services with limited funding, they’re currently facing a budget

shortfall of $200,000 for clinic services. We must work to make sure that our providers have the resources they need to provide high quality health care to the Indian

populations all over the country and especially here in Washington.

I’m looking forward to hearing of the Seattle Indian Health Board’s many accomplishments, especially as they relate to the health needs of urban Indians.

Once again, thank you Mr. Chairman for beginning the reauthorization of the Indian Health Care Improvement Act and for holding this hearing. The time has come

for this bill to finally be reauthorized and I look forward to working with my colleagues in the Senate to make this a reality year.

PREPARED STATEMENT OF HON. BYRON L. DORGAN, U.S. SENATOR FROM NORTH

DAKOTA, VICE CHAIRMAN, COMMITTEE ON INDIAN AFFAIRS

I thank Chairman McCain for his leadership.

I thank my colleagues on the HELP Committee for joining with us in considering

today the Indian Health Care Improvement Act Amendments of 2005. I am particu-
377

larly pleased to note that two of our colleagues from the HELP Committee Senator

Kennedy and Senator Bingaman—have asked to be added as cosponsors of S. 1057.

It is my earnest hope that, by working together—together as authorizing committees, and together with the Administration and representatives of Indian country—

the Indian Health Care Improvement Act will be reauthorized this year.

I know our witnesses today will provide additional statistics regarding health

needs in Indian country. We cannot, in good conscience, be satisfied with the status

quo like this:

• Native American youth are more than twice as likely to commit suicide; in the

Great Plains area the likelihood is as high as 10times.

• American Indians and Alaska Natives are 517 percent more likely to die from

alcoholism.

• 650 percent more likely to die from tuberculosis.

• 318 percent more likely to die from diabetes.

• 204 percent more likely to suffer accidental death.

Over the past few months, my colleagues have heard me speak on the Senate floor

about Indian health care in connection with amendments I have offered to the fiscal

year 2006 budget resolution and the fiscal year 2006 Interior appropriations bill. My

amendments proposed to provide an additional $1 billion for programs not only in

the IHS, but also BIA, tribal colleges, water infrastructure.

I have talked on the Senate floor about people in tribal communities who are

hurting and in desperate need of services. Many of these people I know or have

known, or, in the tragic case of Indian youth suicide, whose surviving family members I have met with.

I know this is true, too, for Dr. Grim and the other witnesses who will testify

today—you all see and hear and experience, every day, the very real need for the

kinds of services and programs and facilities, the kinds of best practices, collaborations and innovations that S. 1057 would authorize for American Indian and Alaska

Native communities. I want to thank each of you who has stuck with this reauthorization process since 1999 and earlier for your persistence and continuing vision.

I want to say that I am particularly pleased with and supportive of the provisions

of title VII of the Indian Health Care Improvement Act Amendments of 2005. This

section of the bill would authorize the Secretary of Health and Human Services—

through the Indian Health Service, the tribal health programs and the urban Indian

organizations—to develop a comprehensive behavioral health prevention and treatment program. Such a program would emphasize collaboration among alcohol and

substance abuse, social services and mental health programs and would benefit all

age groups.

Since the Committee on Indian Affairs’ hearing on June 15 on teen suicide prevention, several more youth suicides have occurred on the Standing Rock Reservation in North and South Dakota. The services and programs for Indian youth, in

particular, the training of paraprofessionals, the education of community leaders,

the construction and staffing of new facilities and research that would be authorized

by title VII will make a very real difference in the lives of men and women who

live at Standing Rock, and all Native Americans.

I look forward to the comments today of the Indian Health Service, the tribes and

urban Indian organizations, and others and appreciate your help in improving this

legislation that will provide creative and effective solutions to address the health

needs of Indian people.

PREPARED STATEMENT OF HON. MICHAEL B. ENZI, U.S. SENATOR FROM WYOMING,

CHAIRMAN, COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS

Good afternoon. Thank you for coming to today’s joint hearing on the Indian

Health Care Improvement Act.

There is no greater challenge before us in the Congress than the work we must

do to continue to improve the quality of the health care that is available to those

living on reservations. Unfortunately, it seems that no matter how much progress

we make, there is always more to do. Today’s hearing will enable us to chart our

current progress and discuss what we can do to increase the services that are available to address the physical and emotional problems that continue to plague American Indians and Alaska Natives.

When the Indian Health Care Improvement Act was first signed into law in 1976,

it was written to address the findings of surveys and studies that indicated that the

health status of American Indians and Alaska Natives was far below that of the

general population. It continues to be a matter of serious concern that, as the health
378

status of most Americans continues to rise, the status of American Indians and

Alaska Natives has not kept pace with the general population.

Studies show that American Indians and Alaska Natives die at a higher rate than

other Americans from alcoholism, tuberculosis, auto accidents, diabetes, homicide,

and suicide.

In addition, a safe and adequate water supply and waste disposal facilities, something we all take for granted, isn’t available in 12 percent of American Indian and

Alaska Native homes—as opposed to 1 percent of the general population. Several

years ago, residents on the Wind River Reservation in Central Wyoming faced a

drinking water shortage that threatened the health and safety of everybody in the

area. Canned drinking water had to be donated to tribal members and local residents. The lack of these basic services makes life even more harsh for these people

and contributes to those already high rates of death.

Coming from Wyoming, I know full well the problems we encounter in the effort

to provide quality health care to all the people of my home State. That is why I

have always made it one of my goals to help bring that perspective to the hearings

and floor debates we have on the issues that affect the people of my State.

When I was first elected to the Senate in 1996 I knew that quality of life issues

on the reservations in Wyoming and throughout the country would continue to be

a top priority of mine. I also knew that, in order to make life better for those living

on the Wind River Indian Reservation specifically, and other reservations nationwide, my staff and I would need to be intensely committed to taking the issues

head-on and looking for creative ways to solve complicated problems.

That is why I put someone on my staff who already had a great deal of experience

with these issues and shared my commitment to act on them. His name is Scotty

Ratliff and he served with me in the Wyoming legislature. I tasked him with the

challenge of helping me to find solutions to the problems on our reservations that

would be both progressive and culturally sensitive.

Tribal leaders are already committed to making things better on their reservations and I congratulate them on their vision and the hard work they have put into

making it a reality. My only question continues to be, ‘‘How can I help?’’ In the

years since I have been in the Senate I have made numerous trips to the Wind

River Reservation in Wyoming and met and spoke with the residents and tribal

leaders. We all want the same goal—a better life for those who live there. I am confident that working together we will continue to make the kind of progress we must

make if we are going to find effective and efficient ways to address the problems

that continue to plague those living on our reservations across the country.

As I noted during my visits to the Wind River Reservation, their problems are

not unique to them. To have an impact on all those who live on reservations from

coast to coast, we will need to take a varied approach to address each of these problems separately. Clearly, people of different ages have different problems. A multifaceted approach to solving each of their problems will require a systemic, as well

as a financial approach.

Local, State, and national governments and agencies must work together with

tribal leaders to focus our resources where they will do the most good. That kind

of approach has the greatest chance of being successful.

Earlier this year the HELP Committee held hearings on the nomination of Michael Leavitt to serve as Secretary of Health and Human Services. I believe we are

fortunate to have Michael Leavitt at the helm of an agency that oversees the health

care needs of the people of reservations all across the country. I am also pleased

Dr. Charles Grim is here with us today. Dr. Grim has an important job to do as

the Director of Indian Health Services and he knows firsthand the level of dedication it will take to steadily improve health care for all American Indians. Dr. Grim

has an unmatched understanding of the needs of Native Americans that you can’t

get from reading reports and memos from people out in the field. I have every confidence in his willingness and his ability to be an important part of the solution to

the health care needs of those on our reservations and beyond.

Again—the good news is—we’re making progress. As we do, we continue to find

so much more that needs to be done. How do we best provide the assistance that

is needed effectively and efficiently? That is the challenge that lies before us.

As we begin to hear from our witnesses, I would like to acknowledge and thank

them all for their willingness to share their experiences with us so that we might

craft a more effective bill to address the health care needs of our American Indian

and Alaskan Native population.

I would also like to welcome Richard Brannan, the chairman of the Northern

Arapaho Business Council of Fort Washakie, WY. No one knows better than he does

the problems faced by those living on reservations and by those who rely on the Indian Health Service for their healthcare needs. No one understands better than he
379

does the necessity of making progress in addressing the health disparities experienced by American Indians. Most important of all, no one is more committed than

he is to making a difference in the lives of all those who live on the reservation.

I know he has an important message to share with us based on his experience

and background with all those who live on the Wind River Reservation. I look forward to his comments and those of our entire list of witnesses. Each of you has a

perspective and a point of view to share that only you can provide. I look forward

to hearing a summary of your prepared remarks so we can address the underlying

issues during our question and answer session.

PREPARED STATEMENT OF HON. DANIEL K. INOUYE, U.S. SENATOR FROM HAWAII

Thank you Mr. Chairman. I commend the committees for holding this hearing

today.

The status of Indian Health Care has significantly improved over the years and

Indian mortality rates have declined. However when compared to the United States

general population Indians have a higher likelihood of dying from diseases such as

alcoholism [770 percent], tuberculosis [650 percent], AND DIABETES [420 percent].

Life expectancy is also 5 years less than the general population. Preventive health

services are needed more than ever as is increased funding for those programs and

services.

In 1976 the Indian Health Care Improvement Act was enacted into law for the

specific purpose of increasing the health status of native peoples. Since then bills

were introduced in the 106th, 107th, 108th, and 109th congresses. Although these

efforts were disappointing, I commend Congress for continuing to work on these crucial issues.

This bill is critical to Indian country. It authorizes behavioral programs, provides

alternatives for rural dental care, and authorizes the Indian Health Service to provide long-term care, are among the many positive changes that I have seen in this

bill. I believe it is congress’ obligation to ensure that Native Americans have full

and timely access to health care.

There is some language in the bill that I am concerned about because it may be

detrimental to tribal sovereignty. However I will continue to work closely with my

colleagues.

I commend my colleagues Senators Dorgan and McCain for drafting this legislation. Once again, thank you for holding this hearing.

PREPARED STATEMENT OF HON. EDWARD M. KENNEDY, U.S. SENATOR FROM

MASSACHUSETTS

I commend Senator McCain, and Senator Enzi for convening this joint hearing on

the Indian Health Care Improvement Reauthorization Act. The Nation has a legal

and moral commitment to provide Native Americans—the Nation’s first Americans—with the best possible health care, and I’m pleased to be a cosponsor of this

important bill.

From the earliest days of colonization that brought infectious diseases to Native

Americans, to the 18th century military conflicts that sought to destroy Native peoples, to the 19th century treaties that sought to confiscate Native lands, to the 20th

century boarding schools that sought to undermine, tribal culture and language, the

history of Native America has often been a shameful part of the history of America.

The Federal Government has long promised better health care to Native Americans in exchange for land. Since at least 1926, the Government has been looking

into the adequacy of such health care, but sadly, many of the inadequacies identified

in the 1920’s still exist today.

Decade after decade, Congress refused to give tribes the resources to develop and

operate their own communities. Too often, it was said that Indian peoples did not

have the expertise to invest such resources wisely to conduct their own governments, operate their own businesses, educate their children, or provide health care

to their people. For generations, this reactionary national mentality poisoned the relationships between tribes and the Federal, State, and local governments.

Native Americans are eager to improve the health status of their people. They deserve control of their own destiny, but they require Congressional action to make

their vision a reality, and it is time for us to honor the commitments we made long

ago.

Chronic underfunding of American Indian and Alaska Native health care by the

Federal Government has weakened the capacity of the Indian Health Service, tribal

governments, and the urban Indian health delivery system to meet the health care
380

needs of the American Indian and Alaskan Native population. The Indian Health

Service per capita expenditures for American Indians and Alaskan Natives are onehalf of what is spent for Medicaid beneficiaries, one- third of that spent by the Veterans Administration, and one-half of what the Federal Government spends on Federal prisoners’ health care.

As a result of inadequate funding, American Indians endure health conditions

most Americans would not tolerate.

Native Americans are 8 times more likely to die from alcoholism, 7 times more

likely to die from tuberculosis, 5 times more likely to die from diabetes, and 50 percent more likely to die from pneumonia or influenza than the rest of the United

States, including white and minority populations.

Native American infants die at a rate 21⁄2 times greater than the rate for white

infants.

Native Americans are at a higher risk for mental health disorders than other racial and ethnic groups in the United States.

Their cardiovascular disease rate is twice that of the general population.

Their life expectancy is 71 years—nearly 5 years less than the rest of the population.

These statistics represent real people who deserve more from the U.S. Government.

The Indian Health Care Improvement Act has been amended many times, but it

was only extended through 2001. It is long past time to reauthorize this act.

Congress has been working to do so for the past 5 years. The current legislation

reflects years of consultation with the Tribal National Steering Committee and

holds great promise for improving the lives of Native Americans through comprehensive public health efforts. Despite widespread support, the bill has not been

brought to the Senate floor for a vote.

A better future is well within our grasp. We have a unique opportunity to make

much more rapid progress on the long journey toward respect for our First Americans. We must bring the Indian Health Care Improvement Reauthorization Act to

the floor. We must pass this legislation. Until every American Indian and Alaskan

Native receives first class health care, we will never give up the fight. I look forward

to this hearing and to the testimony of each of the witnesses.

PREPARED STATEMENT OF HON. JOHN MCCAIN, U.S. SENATOR FROM ARIZONA,

CHAIRMAN, COMMITTEE ON INDIAN AFFAIRS

Good afternoon. The bill before us today, S. 1057, is the latest iteration of the reauthorization of Indian Health Care Improvement Act that has lingered in the Senate for many years. And while there was much debate about the measure at the

end of the last Congress, the need to improve the provision of health care services

for Native Americans is undebatable. I am very heartened that our colleagues from

the HELP Committee under the leadership of Chairman Enzi and Ranking Member

Kennedy have so actively engaged in advancing the legislative process. I appreciate

not only their support, but the expertise and insight that the HELP Committee

brings to the effort.

Nearly 30 years ago, Congress enacted the Indian Health Care Improvement Act

to meet the fundamental trust obligation of the United States in providing comprehensive health care to American Indians and Alaska Natives. It was last reauthorized in 1992—13 years ago.

This act is the statutory framework for the Indian health system and covers just

about every aspect of Indian healthcare. S. 1057 builds on that framework by providing significant advancements in health care delivery and by promoting local decisionmaking, tribal self-determination and cooperation with the Indian Health Service.

Those critical improvements include increased access to care, especially for Indian

children and low-income Indians, programs designed to recruit and retain

healthcare professionals on Indian reservations, and alternative financing for

healthcare facilities and other services.

Reauthorization of this Act is a high legislative priority. It has been 6 years in

the making—far too long for the much needed improvements. Substantial work was

completed last year and we have but a few remaining issues that I hope we can

resolve quickly so that the bill can be enacted soon. I welcome the witnesses and

look forward to the testimony.
381

PREPARED STATEMENT OF HON. PATTY MURRAY, U.S. SENATOR FROM WASHINGTON

Thank you Mr. Chairman.

I want to thank Chairman Enzi for holding this joint hearing. I’m happy that my

colleagues on the HELP committee have this opportunity to learn more about the

crisis facing tribal communities today and why this bill is so critically important.

Mr. Chairman, I believe improving the quality and access of health care in tribal

communities is one of the Federal Government’s greatest treaty obligations. But

when it comes to providing that care——

• the Federal Government has fallen short of its moral and legal obligation.

Chairman Enzi, I’d ask for your commitment to continue to work together on this

important issue so that we can help the Committee Indian Affairs move this bill

forward.

I know you have some concerns about the bill and I’d like to work with you to

address them. As you may know, this legislation has been through an exhaustive

review by tribal leaders and health professionals, the Committee on Indian Affairs

and the Administration.

And in light of two reports by the U.S. Commission on Civil Rights documenting

the health care disparities facing Native Americans living on reservations and in

urban areas it is time for the Congress to reauthorize this law.

Finally, I’d like to join with my colleagues in welcoming Ralph Forquera to the

committee. Ralph is a national leader on issues affecting Native Americans living

in urban areas and I’m pleased to see he’s here today representing the Seattle Indian Health Board.

Thank you.

PREPARED STATEMENT OF MARK KELSO, DDS, NORTON SOUND DENTAL DIRECTOR

NOME, AK

As a dentist with 19 years of direct patient care experience in Western Alaska,

I believe that I can speak with great credibility regarding the dental needs of the

indigenous people of the region. I have observed the cycle of destructive dental disease repeated from one generation to the next. The current method of itinerating

dentists to rural communities for several weeks annually does little to elevate the

public’s aptitude toward the importance of good oral health. The dentists’ role is

viewed as one of simply alleviating pain and infection or repairing decayed teeth.

While this service is important, it ultimately shifts the burden of one’s own responsibility in the maintenance of their oral health to that of the provider.

The dentists being of different ethnicity and cultural upbringing are not easily

viewed as a role model for children and young adults to emulate. The dentists’ short

duration in the village also hampers their ability to bring about long-term patient

motivation. Patients respect the dentists’ advice while they are there, but their enthusiasm to better clean their teeth and limit the intake of sugary foods soon fades

upon the dentists’ departure. Established poor dental habits re-emerge.

A dental chart review demonstrates that patients receive the care that is warranted. An ongoing trend of preschool children being afflicted with rampant dental

decay in the baby teeth and subsequent restoration of these teeth either by multiple

sedation appointments locally or by operating room procedures in Anchorage is a

frequent occurrence. The erupting adult teeth are cleaned, sealed, and fluoridated

but ultimately succumb to the rigors of poor diet and hygiene. The teeth usually receive several fillings of increasing complexity. In too many cases, the teeth reach

a diseased state in which extraction of all of the teeth is the only viable treatment.

Full dentures are fabricated. An analysis of the cost and effort to provide all of these

services with the end result of being an edentulous teenager or young adult is sobering. Thousands of dollars per patient in both dental and hospital services along with

associated travel were expended.

A change in public perception regarding the importance of good oral health is

needed. Native American dental providers are key in this process. Dental Therapists, residing and working in villages of a high oral disease rate, will be a constant

dental presence in those communities. They will have the luxury to examine and

treat patients more than once a year. More time can be spent on improving patients’

oral hygiene index. Weekly fluoride rinse programs in the school will be an important job duty. But to gain the respect of the communities, the Dental Therapists

must be known as the primary dental health care providers. They will obtain this

status by alleviating existing need. The Dental Therapists must be able to perform

routine fillings, treat infected nerves in children’s teeth, and extract painful, hopeless teeth. The dentists will still itinerate through the villages to perform more com-
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plex treatment, eventually providing higher level services such as root canal completions, permanent crowns and bridges, denture fabrications, and orthodontic assessments not currently available in these remote locations. As the level of dental care

increased in the hub-clinic in Nome, the dental expectation of the community did

too. A decrease in basic dental disease followed. Such a model could be extended

to the villages through the use of Dental Therapists.

Another important aspect is the influence that the Dental Therapists will have

on the school-age children and young adults. A criterion for the selection of all of

the Dental Therapists in the Norton Sound region was that they all possess nice

teeth, value a healthy smile, and practice good oral habits in their daily lives. Many

junior and senior high school girls in the villages, the future mothers of the next

generation, desire to look their best like most American girls. They may wear trendy

clothes, style their hair, and apply cosmetics, but the deteriorated condition of their

teeth negates these other measures. The Dental Therapists will frequently reinforce

the need to alter dietary choices and practice daily oral hygiene to improve this segment of the population’s oral health. Through the Dental Therapists own actions,

they can inspire the youth that it is important and ‘‘cool’’ to have good teeth. It will

not be socially acceptable any longer to brandish a smile of decay -riddled teeth or

missing teeth altogether. Usually the children’s teeth mirror those of the mother,

either good or bad. This will be an excellent opportunity to stop the generational

cycle of rampant tooth decay and premature tooth, loss. The Dental Therapists will

be an ever-present, walking advertisement to the importance of good oral health.

I urge the Senate Committees on Indian Affairs and Health, Education, Labor,

and Pensions to support S. 1057 as it is written. The ability of the Dental Therapists to perform the procedures of fillings, dental pulp treatments, and basic extractions is crucial to their success. The Dental Therapists’ potential to bring about positive long-term change is greater than that of any number of itinerant dentists, either compensated or volunteer.

PREPARED STATEMENT OF TOM KOVALESKI, DDS, DIRECTOR, SOUTHCENTRAL

FOUNDATION, [SCF] DENTAL PROGRAM

Thank you for the opportunity to submit testimony to the SCIA and HELP Committee regarding the practice of DHATs and section 121 of S. 1057, the Indian

Health Care Improvement Act Amendments of 2005. Please include my testimony

in the record of the July 14, 2005 hearing regarding S. 1057.

I was honored to be one of the four authors of the paper, ‘‘Integrated Dental

Health Program for Alaska Native Populations.’’ Since the first draft was released,

I have been in regular discussion with tribal dental health program directors in

Alaska. I have stated to them repeatedly that in my view the COHP model should

be viewed by them, by the ADA, and by Congress, not as a substitute for DHATs,

but rather as a tool for achieving additional efficiencies and improvements. In my

view, there is a place for implementation of COHP and DHATs as part of an integrated dental health program.

I do not endorse the conclusion of the ADA that COHP can substitute for DHATs

in resolving the crisis regarding access to dental services among Alaska Natives. I

would recommend both programs be implemented as pilot programs with the results

evaluated closely. While I think both SCF’s efficiency expertise and the full implementation of a COHP model may help the crisis, there is still a pressing need for

additional practitioners that expanded function dental hygienists and DHATs could

help fill. Throughout the development of the DHAT standards ultimately adopted

by the Community Health Aide Program Certification Board, I actively participated

with other dental providers in reviewing the Standards and the research base for

mid-level dental practice and shared my concerns around the training and quality

assurance components. I believe that DHATs have the potential to be high quality

providers with proper training and quality assurance.

As a practicing, licensed dentist responsible for a large program serving both an

underserved urban and rural populations, I do not believe the dental community can

afford to reject any responsible approach to expanding access to dental services. I

believe dental assistant training, increased capacity, expanded function hygienists,

COHP, and DHATs, provide such a responsible options for reducing the backlog of

dental disease in Alaska.

I urge Congress to not make changes in the authority of the community health

aide program pursuant to section 121 of the Indian Health Care Improvement Act

under which DHATs are certified so that we can evaluate their impact along with

other strategies.
383

If I can offer additional information that will help you in your deliberations,

please let me know.

INDIAN HEALTH CARE IMPROVEMENT ACT: QUESTIONS FOR THE RECORD

(SENATOR HATCH)

JULY 15, 2005

Panel I

Questions for Ms. Rachel Joseph

National Steering Committee

Chairperson, Lone-Pine Paiute Shoshone Reservation

No. 1. Title VII would authorize a comprehensive behavioral health program, reflecting tribal values and collaboration among various substance abuse, social service, and mental health programs. You spoke of the need to have a ‘‘systems of care’’

approach to mental health in addition to this comprehensive package. Can you tell

me specifically what this ‘‘systems of care’’ approach would add to the comprehensive program already outlined in title VII?

No. 2. The National Steering Committee has a long history with this legislation.

Can you tell us what the major stumbling blocks have been to passing this bill in

the past, and how this bill has addressed these issues?

Panel II

Questions for Mr. Don Kashevaroff

Alaska Native Health Tribal Consortium and Tribal SelfGovernance Advisory Committee

No. 1. What, specifically, are the concerns on the part of the Administration with

negotiated rulemaking and how does this bill address those concerns? Why is negotiated rulemaking of particular importance to tribes?

Questions for Mr. Richard Brannan,

Chairman, Northern Arapaho Tribe

No. 1. In your testimony, you stated that the Arapaho Tribe has a high disproportionate number of diabetics—would you please describe the current state of the dialysis program available to the Arapaho Tribe?

No. 2. Regarding the issue of care for the elderly, you mentioned that most

Arapho elderly, choose to remain in their own homes—do you believe that they

would still remain in their own homes if better facilities were available to them?

No. 3. I understand that family and domestic violence remains a large problem

facing the American Indian population, and that expansion of related services is

vital to combating that problem. What services are currently provided on the Wind

River Reservation with regard to family and domestic violence; and what services

do you suggest be added to enhance the current program?

Questions for Mr. Ralph Forquera,

Executive Director, Seattle Indian Health Board;

and Director, Urban Indian Health Institute

No. 1. I am concerned by your statement about the lack of available data needed

to address the growing health crisis among urban Indians—it appears that this crisis may be much larger than we are even capable of gauging. What are the main

reasons it is so difficult to collect data of urban Indians; and, do you have suggestions of what Congress can do to improve the data collection process?

No. 2. Do you consider the trend toward urbanization to be increasing?

No. 3. With regard to the Federal Tort Claim Act, you stated that inclusion could

save considerable expense for programs that are now purchasing private liability insurance to support their work ? can you provide a hypothetical estimate of those

savings?

Panel III

Questions for Dr. Mary Williard, D.D.S.

Yukon-Kuskokwim Health Corporation, AK

No. 1. You support the current program which permits Dental Health Aide Therapists (DHAT) to perform various procedures on patients in remote areas. The American Dental Association has concerns with three of these procedures (extracting

teeth, drilling cavities, and pulpotomies). What programs are currently in operation

that are similar to the DHAT program? Do participants in these programs perform

these controversial procedures? Can you provide us information on these programs:
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where they are, how long they have been in operation, what studies have been done

assessing their safety and effectiveness, particularly with regard to these three procedures?

No. 2. You mention that the dental therapists will work under the supervision

of a dentist. Who are these dentists and how can they supervise dental therapists

who are in remote villages? What ‘‘back-up’’ exists if a procedure runs into unexpected complications?
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Æ